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ON 



LYING-IN INSTITUTIONS. 



LOVDONt pnniniD bt 

8F0TTIBW00DB AlTD CO., HSV-BTBKKT BQUABB 
AKD FABLIAMBNT BTBXXT 



INTEODUCTORT NOTES 



LYING-IN INSTITUTIONS. 



A PROPOSAL FOE 

OEGAMISING AN mSTITUTION FOE TEAINIHG M3DWITES 

AND JUDWIFEBY NUBSEB. 



Floeence Nightingale. 






LONDON : 

LONGMANS, GBEEN, AND CO. 
1871. 



/r/. fyt. ns~. 



k 



TF I may dedicate, without 'permission,' these small 
* Notes' to the shade of Socrates' Mother, may 
I likewise, without presumption, call to my help the 
questioning shade of her Son, that I who write may 
have the spirit of questioning aright, and that those 
who read may learn not of me but of themselves ? 

And, further, has he not said: 'The midwives are 
respectable women, and have a character to lose'? 



PEEFACE. 



In the year 1862 the Committee of the Nightingale Fund, 
with a view to extending the advantages of their Training 
Institution, entered into an arrangement with the authorities 
of St. John's House, under which wards were fitted up in 
the new part of King's College Hospital, opening out of the 
great staircase and shut up within their own doors, for the 
reception of Midwifery cases. The wards were under the 
charge of the (then) Lady Superintendent. Arrangements 
were made for medical attendance, a skilled midwife was 
engaged, a certain number of pupil nurses were admitted 
for training; and hopes were entertained that this new 
branch of our Training School would confer a great benefit 
on the poor, especially in country districts, where trained 
Midwifery nurses are needed. 

Every precaution had apparently been taken to render 
the Midwifery Department perfectly safe ; and it was not 
until the school had been upwards of five years in existence, 
that the attention of the Nightingale Committee was called 



VUl PREFACE. 

to the fact that deaths from puerperal diseases had taken 
place in each of the preceding years. 

During the period of nearly six years that the wards were 
in use, the records show that 780 women had been delivered 
in the institution, and that out of this number twenty-six * 
had died — a mortality of 33*3 per 1,000. 

The most fatal year was 1867, in which year nine out of 
the twenty-six deaths took place. In the month of January 
a pregnant woman, who was under treatment for erysipelas 
in the hospital, was delivered in a general medical ward. 
No. 4, in the first-built wing of the hospital. A midwife 
was tol^ off to attend her, who was not suffered to be near 
the midwifery wards for a considerable time. The erysipelas 
case died of puerperal fever ; and this death was followed by 
a succession of puerperal deaths in the lying-in wards until 
November, when the wards were as soon as possible closed. 

An analysis of the causes of death showed that, with the 
exception of one death from ha3morrhage, not a single 
death had taken place from accidents incidental to child- 
bearing during the whole six years. There were three 
deaths due to diseases not necessarily concomitants of this 
condition ; while of the others, twenty-three in number, no 
fewer than seventeen were due to puerperal fever, three to 
puerperal peritonitis, two to pyaemia, and one to metritis. 



* Exclusive of the case of a poor woman who was delivered in a cab, and 
died in the hospital of post partum hiemorrhage. 



The following table gives the actual fates and dates : — 
Midwifery Statistics, King's College Hospital. 





Yea 


^1 


PaMlCaws 1 






BirtU 


^.X... 


Caun ot DeaUi 


Dsteof 
Death 


I^kbonffi 




1895 


97 

105 
141 

ISO 


JM1.10 

April 29 

Sir 

Jan. 80 

Jime24 
Mu. 3( 

oot.a 

Dec.' 4 
Jan. ID 

Juna4 
Jnlj2fi 


Tnlni 
Natural 

Natural 

Bnr^ In cab 

Por«!» 

Natural 

( PlBCpnta pifflTia. ) 
1 Turning i 

l[Had' Brjsirelaal 
iwhenadmlttal'll 

Katnml 

JTwlns; iBldfad.l 
t and by turning) 


IPhthlBla and pDBrperall 

PoBrperal [ever 
Pderperal raver 

fflnbdli™ 
Puerperal tcTcr 

1 pncrperal (ever f 
Pnerperal (sTflT 

JKetalned placenta, puor-l 
1 peral fever / 
BmpliyMmaandbfonchltia 

Puerperal fever 
i puerperal feyer J 

Puerperal feror 
PjKmiB 
Puerperal fever 

Pntrptral levBT 
J Laceration of vagina, pner- 1 
1 pcral ftfTtr ) 


DK1.30 

si 

July 30 

Jm.'so 
April 10 
Oct. 10 
Kov. le 

Dec. 31 

III 

Aug. 11 
Not. U 


lin4T 




lVt.2 


78. 


- 


- 


— dcatba : 37 


llnm 



as couaneii In Ho. 4 nrd.' 



Under these deplorable circumstancea the closing of the 
wards was a matter of course ; and since that event we 
have been aDsiously enquiring whether it would be justi- 
fiable to re-open our Midwifery Nursing School under other 
conditions. 



X PREFACE. 

This question is discussed in the following pages, from a 
basis of statistical facts supplied by the best authorities ; 
and a few proposals have been added, with the view of 
turning to the best account our past experience, by extract- 
ing from it any leading principles which may present them- 
selves for practical appUcation in the future construction and 
management of Lying-in Institutions, and more especially 
in connection with means of training Midwifery nurses. 

These Introductory Notes, collected and put together 
under circumstances of aU but overwhelming business and 
illness, are now thrown out merely as a nucleus, in the hope 
that others will be kind enough to supplement, to add, and 
to alter ; in fact, only as a hook with a modest little fish on 
it — a bait to catch other and finer fish. 

The facts themselves, the nucleus, have been made as 
correct as it was possible, and as would have been done for 
a finished work. But the facts themselves are only put 
forth as feelers — ^feelers to feel my own way. 

I need scarcely say either that these * Notes ' are not at all 
meant to discuss every point which presents itself in Mid- 
wifery statistics. On the contrary, they are, for the moment, 
purposely limited to the consideration of facts immediately 
relating to the present object. 

Let me thank once more with true gratitude all those 
who have so kindly supplied me with help and information, 
some of whose names will appear in the following pages. 



CONTENTS. 



PAOB 

Pkeface . ....... vii-x 



Table of Midwifery Statistics, King^s CoUege Hospital 

What is the real normal Death-rate of Lying-in Women f . 

MiswiFEBT Statistics ...... 

Normal Death-Kate op Lying-in Women in England 

Table 1,-— Mortality after Childbirth in England, 1867 

Table II. — Mortality per 1,000 after Delivery from Puerperal Diseases 
and Accidents of Childbirth .... 

NoEMAL Moetality OP Lting-in Women in different Countries 

Table III. — Death-rate from all Causes amotigst Women delivered in 
their own Homes ...... 

Objections to the Data ...... 

Estimated Approximate Home Death-rate 

Death-rates in Lting-in Institutions 

Table IV. — Admissions and Deaths in Childbirth in eight Women^s 
Hospitals {Military) . . . . . 

Table V. — Statistics of Midwifery Wards in Liverpool Workhouse 

Table VI. — Mortality after Childbirth in forty London Workhouses 

Table VII. — Mortality in Queen Chariot te^s Hospital 



IX 

1 
2 
4 



6 

7 

8 

9 

11 

11 

12 
13 
13 

14 



.^C-.' 



Xll 



CONTENTS. 



PAGE 

Table VIII. — Mortality per IflOO from all Comes after Delivery . 15 

Table IX. — Mortality in Lying-in Ward, King's College Hospital . 15 

Table X. — Death-rate from all causes in Lying-in Hospitals . . 17 

Table XL — Mortality per 1,000 among Lying-in Women at Paris 

HospitcdSf 1861 ....... 20 

Table XII. — Mortality per 1,000 ammig Lying-in Women at Paris 

Hospitals, 1862 ....... 20 

Table XIII. — Mortality per 1,000 among Lying-in Women at Paris 

Hospitals, 1863 ....... 21 

Classhtcatton op Cattses op Mobtalitt in Lying-in Institutions . 21 

Causes of high Death-rates in Lting-in Institutions , . 23 

Puerperal Fever , . . . , . .24 

Admission of Students • . . • • .25 

Effect of Numbers . . . • . , .26 

Danger of Puerperal Epidemics . • • . .31 

Fatality of Lying-in Wards in General Hospitals • . .32 

Inplxtence op Construction and Management op Lying-in Wards 

on the Death-rate • • . . . .33 

MatemitS, Paris . • . . . . .34 

HSpital de la Clinique, Paris . . . . . .36 

Queen Charlotte^s Lying-in Hospital, London . . .38 

Midwifery Wards, King's College Hospital, London . . .40 

Improved Lying-in Ward Construction . . . .41 

Military Female Hospitals . . . . . .41 

Table XIV. — Classification of Causes of Death in C?nldbirth in Fight 

Women^s Hospitals {Military) . . . . .43 

Proposed new Female Hospital at Portsmouth . . . .45 

Should Medical Stxtdents be admitted to Lying-in Hospital 

Practice? ....... 48 



CONTENTS. XIU 

PAGE 

Inplttencb op Time spent in a Lying-in Wabd on the Death-rate 50 

Efpegt op Good Management on the Sttcoess op Lying-in 

Establishments . . . . . . .52 

Liverpool Workhouse . . . . . . .53 

Summary of Cases Delivered in the Lying-m Wards of Liverpool 
Workhouse, 186S-IS70 ...... 53 

Summary of Deaths arid Causes of Death in the same, 1858-1870 . 54 
London Workhouses . . . . . . .58 

Management op Militaby Lying-in Wabds . . . .62 

Note on altogether disconnecting Lyvng^ Institutions even with the very 

name of Hospital . . . . . . .64 

Eeoapitulation ........ 65 

Table XV. — Comparative MortaUty among Lying-in Women in Hospitals 

and at Home ....... 68 

Can the Abbangement and Management op Lying-in Institutions 

BE Impbovbd? . . . . . . .68 



CHAPTER II. 

CONSTBXrCTION AND MANAGEMENT OP A LyING-IN INSTITUTION AND 

Training School pob Midwives and Midwipeby Nubses 

I. CONSTBXrCTION OP A LyING-IN INSTITUTION . 

1. How many Beds to a Ward? 

Table XVL — Proposed Registry of Midwifery Cases 

2. How many Wards to a Floor f , 

3. How many Floors to a Pavilion {Hut or Cottage) f 
How many Beds to a Pavilion or Hut f 
Hoto many Pavilions or Huts to a Lying-m Institution f 

4. jHow much Space to the Bedf 
The Delivery Ward .... 



72 

74 
74 

75 
76 
76 
76 

77 
77 



XIV 



CONTENTS. 



6. How many Windows to a Bed f . 

6. TVhat are Healthy Walls, and Ceilings, and Floors f 

7. WTutt is a Healthy and Well-lighted Delivery Wardf 

8. Sddleny^ Lavatory J W,C, , 

9. How to ventilate Lyvng-in Wards , 

10. Furniture, Bedding, Linen 

11. Water'Supply, Drainage, Washing 
Medical Officer^ s Room and Waiting Room 

13. Segregation Ward 

14. Kitchen .... 
Site .... 

II. Maitagement .... 

First Rule of Good Management 
Second Rule of Good Management 
Third Rule of Good Managefnent 

III. TBAiNiNe School fob Midwiyes . 

DeSCBIPTION 07 SSETCH-PLANS OP PbOPOSBD INSTITUTION 

A Lying-in Institution for 40 beds (32 to 36 occupied), with a training 
school for SOpupU Midtoives and Nurses • • 

Appendix: Miswipebt as a Cabeeb pob Edttcated Woken 



PAGE 

78 
78 
79 
81 
83 
84 
86 
86 
86 
86 
86 

90 
90 
91 
93 

94 
100 

102 
106 



LIST OF PLANS. 



NO. 

1. QuEEif Charlotte's Lying-in Hospital, London . to face page 88 



2. Wooden Lying-in Uttt in Oolohesteb Camp • . ,, 44 



3. Plan op a Lying-in Waed, Four Beds • . . „ 100 

4. Plan op a Lying-in Floor, Four one-bed Rooms . „ 101 

5. Plan op a Lying-in Institution por 40 (32 to 36 occupied) 

Beds, with Training School por 30 Pupil Midwttes „ 104 



NOTES 



ON 



LYING-IN INSTITUTIONS. 



The first step to be taken in the discussion is to enquire, 
What is the real normal death-rate of lying-in women ? And, 
having ascertained this to the extent which existing data 
may enable us to do, we must compare this death-rate with 
the rates occurring in establishments into which parturition 
cases are received in numbers. We have then to classify 
the causes of death, so far as we can, from the data, with the 
view of ascertaining whether any particular cause of death 
predominates in lying-in institutions ; and, if so, why so ? 
And finally, seeing that everybody must be born, that 
every birth in civihsed countries is as a rule attended by 
somebody, and ought to be by a skilled attendant ; since, 
therefore, the attendance upon lying-in women is the widest 
practice in the world, and these attendants should be trained ; 
we must decide the great question as to whether a training- 
school for midwifery nurses can be safely conducted in any 

B 



2 NOTES ON LYING-IN INSTITUTIONS. 

building receiving a number of parturition cases, or whether 
such nurses must be only trained at the bedside in the patient's 
own home, with far more diflSculty and far less chance of 
success. 



MIDWIFERY STATISTICS. 

It must be admitted, at the very outset of this enquiry, 
that midwifery statistics are in an unsatisfactory condition. 
To say the least of it, there has been as much discussion re- 
garding mortality and its causes among lying-in women as 
there has been regarding' the mortality due to hospitals. 
Yet there appears to have been no uniform system of record 
of deaths, or of the causes of death, in many institutions, 
and no common agreement as to the period after deUvery 
within which deaths should be counted as due to the puer- 
peral condition. Many of the most important institutions 
in Europe merely record the deaths occurring during the 
period women are in hospital, and they appear not unfre- 
quently to do this without any reference to the causes. 
Similar defects are obvious enough in the records of home 
deliveries ; and hence it follows that the mass of statistics 
which have been accumulated regarding home and hospital 
deliveries, admit of comparison only in one element, namely, 
the total deaths to total deliveries, and this only approxi- 
mately. 

Dr. Matthews Duncan, in his recent work on the 'Mortality 
of Childbed and Maternity Hospitals,' has dwelt forcibly on 
these defects in midwifery statistics, and has made out a 



MIDWIFERY STATISTICS. 3 

strong case for improvement in records. But, as will be 
afterwards shown, with all their defects, midwifery statistics 
point to one truth ; namely, that there is a large amount of 
preventible mortahty in midwifery practice, and that, as a 
general rule, the mortality is far, far greater in lying-in hos- 
pitals than among women lying-in at home. 

There are several of what may be called secondary in- 
jfluences also, which must affect to a certain extent the 
results of comparison of death-rates among different groups 
of lying-in cases. Such are the ages of women, the num- 
ber of the pregnancy, the duration of labour, and the like. 
It is impossible, in the present state of our information, to 
attribute to each, or all of these, their due influence ; neither, 
if we could do so, would it materially affect the general 
result just stated. But it is otherwise with another class of 
conditions, of which statistics take no cognizance. Such 
are the general sanitary state of hospitals, wards, houses, 
and rooms where deliveries take place; the management 
adopted ; the classes of patients ; their state of health 
and stamina before delivery ; the time they are kept in mid- 
wifery wards before and after delivery. These elements 
are directly connected with the questions at issue, and yet 
our information regarding them is by no means so full as 
we could wish — indeed is almost nothing. 

Our only resource at present is to deal with such statis- 
tical information as we possess, and to ascertain fairly what 
it tells us. This we shall now endeavour to do, beginning 
with an estimate of the normal mortality due to childbirth 
in various European countries. 

3 2 



NOTES ON LYING-IN INSTITUTIONS. 



NORMAL DEATH'RATE OF LYING-IN WOMEN IN ENGLAND. 



In the Kegistrar-General's Thirtieth Annual Keport, 1867, 
there is an instructive series of tables, giving approximately 
the present normal death-rate among lying-in women in 
England. 

One of these tables (abstracted on Table I.) shows that, 
including deliveries in lying-in hospitals, there were in 
England, during the year 1867, 768,349 births, and that 
3,933 women died in childbed. This gives an approximate 
total mortahty of 5-1 per 1,000 from all causes. 

Table I. — Mortality after Childbirth in England, 1867 
{Registrar-Oenerara Thirtieth Annual Report), 



Total Births 


Deaths from 

Accidents In 

Childbirth 


Deaths from 

Puerperal 

Diseases 


Deaths from 

Miasmatic 

Diseases 


Deaths from 

Consumption 

and Chest 

Diseases 


Deaths from 

aU Other 

Causes 


Total Deaths 


768,349 


2,346 


1,066 


137 


230 


154 


3,933 



The causes of mortality are also given in Table I. as 
follows : — 

1. There were 2,346 deaths by accidents of childbirth 
(haemorrhage, convulsions, exhaustion, mania, &c.). 

2. There were 1,066 deaths due to puerperal diseases 
(puerperal fever, puerperal peritonitis, metritis, pyaemia, &c.). 

3. Of the remaining 521 deaths, 137 were due to non- 
puerperal fevers and eruptive fevers ; 230 were occasioned 



NORMAL DEATH RATE. 5 

by consumption and other chest diseases, and 154 by other 
causes. 

4. By adding together deaths from puerperal diseases and 
those from fevers, we find that, out of a total mortality of 
3,933, the deaths from diseases more or less connected with 
what is called 'blood-poisoning' amounted to 1,203, or 
rather more than 30 per cent, of the total mortality, 

5. The mortaUty per 1,000 deliveries (or rather per 1,000 
births) from each class of causes in England, in 1867, stands 
-thus : — 

Accidents of childbirth • « • .3 per 1^000 

Puerperal diseases • • • • • 1*4 „ „ 

Others, including non-puerperal fevers . • '7 „ „ 

Total • • . • . 6-1 ,, ,, 

The same Keport gives the following puerperal death- 
rates for all England during 13 years, 1855 to 1867 (see 
Table II.). 

Accidents of childbirth . . . . 3-22 per 1,000 

Puerperal diseases • • • • 1*61 ,, ,, 

Total, e2u;lusiye of other deaths • • 4*83 „ „ 

An important element in the analysis of these death-rates 
is their relative prevalence in town and country. This is 
abstracted on Table 11. from the Kegistrar-Generars Keport 
for a period of ten years, as follows : — 

Deaths from Accidents of Childbirth and Puerperal Diseases* 

England, 64 healthy districts, 312,402 deliveries . 4-3 per 1000 
Ditto, 11 large towns, 1,402,304 deliveries . 4-9 „ „ 

In other words, out, of every 5,000 deliveries in towns 
there are three more deaths from accidents of childbirth and 



6 



NOTES ON LYING-IN INSTITUTIONS. 



puerperal diseases than occur among the same number of 
deUveries in healthy districts. 

These facts, with a small deduction for the higher death- 
rates in lying-in hospitals, give the present mortaUty in 
English homes. They appear to show that puerperal women 
are subject to something of the same law of increase of death- 
rates in towns as other people, but part of the increase is no 
doubt due to the higher death-rates in dehvery-wards in these 
towns. The facts also appear to indicate a probable reduc- 
tion of death-rates among lying-in women in England, from 
the extension of public health improvements both in town 
and country. 



Table II. — Table Showing the Mortality per Thxmsand after 
DeUvery frora Puerperal Diseases and Accidents of Childbirth. 



Places 

... . t 


Mortality Per Thousand Deliveries 


Puerperal 
Dideases 


AccidentB 
of Child- 
birth 


Puerperal 
Diseases and 
Accidents of 

Childbirth 


King's College lying-in ward, 5 years . 

1861 f . 

12 Parisian Hospital8l862 • . 

1863 I . 

Queen Charlotte's Lying-in Hospital, 40 years 

27 London workhouses, in which both de- 
liyeries and deaths have taken place 

40 London workhouses, including those with- 
out deaths, 5 years .... 

Liverpool Workhouse lying-in wards, 13 years 

All fmgland, 13 years 

Ditto, 64 healthy districts (312,402 deliveries), 
10 years . ' . 

Ditto, 11 large towns (1,402,304 deliveries), 
10 years ..... 

8 military lying-in hospitals, 2 to 12 years • 


29-4 

14-3 

4-1 

3-3 
3-4 
1-61 

3-9 




5-3 

21 

1-7 
2-2 
3-22 

3-4 


29-4 
76-2 
56-7 
60-6 
19-6 

6-2 

50 
5-6 
4-83 

4-3 

4-9 
7-3 



NORMAL MORTALITY IN DIFFERENT COUNTRIES. 



NORMAL MORTALITY AMONG LYING-IN WOMEN IN 

DIFFERENT COUNTRIES. 

The next step in the enquiry is to ascertain, so far as it 
may be possible to do so, what is the death-rate among 
lying-in women delivered at their own homes in different 
European countries. Besides the mortality statistics for 
healthy districts in England, already given, the only avail- 
able data for this information are reports of public institutes 
having outdoor midwifery practice, and any records of pri- 
vate practice which may have been published. Li adducing 
these data, however, it is necessary to do so with the reser- 
vation already made that their accuracy is only approximate. 

The most extensive series of data of this class is given by 
Dr. Le Fort in his able treatise ' Des Matemit^s,' for a num- 
ber of institutions in different European countries. Tke 
facts from Dr. Le Fort's book are abstracted on Table III., in 
which it is shown that out of 934,781 deliveries at home, 
in Edinburgh, London, Paris, Leipzic, Berlin, Munich, 
Greifswald, Stettin, and St. Petersburg, there were 4,405 
deaths, equivalent to a mortality of 4:7 per 1,000. When 
compared with the Kegistrar-General's returns for town 
districts, this rate is apparently somevhat too low ; it is 
only an approximation, but still sufficiently near the rate 
given by the Eegistrar-General to show that there is a true 
death-rate for home deliveries not far removed from the 
Kegistrar-General's figure. 



8 



NOTES ON LYING-IN INSTITUnONS. 



Table III. — Table Shx/wvag the Deathrrate from aU Causes 
amongst Wom>en Delivered in their own Homes. {Abstra,cted 
from Dr. Le Forfs Tables.) 



Flaoei 


Ko.of 

Years of 

Obserration 


DdiTeriet 


Deaths 


Deaths per 
.Thonsand 


Edinburgh • • • 


1 


5,186 


28 


5 


London : 










Westminster General Dispen- 










sary 


11 


7,717 


17 


2 


Ditto Beneyolent Institution . 


7 


4,761 


8 


1 


Royal Maternity Chanty • 


6 


17,242 


53 


3 


London population • 


6 


662,623 


2,222 


3-9 


St Thomas' Hospital . 


7 


8,512 


9 


2-5 


Guy's Hospital • 


8 


11,928 


36 


3 


Ditto • • • • 


1 


1,505 


4 


2 


Ditto • • « • 


1 


1,702 


8 


1-7 


Ditto • • • 


1 


1,576 


11 


6 


Paris: 










12th Arrondissement • 


1 


8,222 


10 


3 


Bureau de BienfiEdsance 


1 


6,212 


32 


5 


Ditto . • • . 


1 


6,422 


39 


6 


City of Paris . 


1 


44,481 


262 


5 


Pitto .... 


1 


42,796 


226 


5 


Leipzig Polyclinique • • 


11 


1,203 


13 


10 


Berlin ^^ • 


1 


500 


7 


14 


Munich ^ . 


5 


1,911 


16 


8 


Greifswald ,, « 


4 


295 


6 


20 


Stettin ff • • 


17 


375 








St Petersburg . • 
Total 


15 


209,612 


1,403 


6-6 


— 


934^781 


4^405 


4-7 



APPROXIMATE HOME DEATH-RATE. 9 

St. George's Hospital Statistics for ' the 6 years preceding 
1870 show only one maternal death in every 305 cases ' in 
the Out-door Maternity Department. 

From home records, it is hoped at some future time to 
give many more data of this kind, and to distinguish the 
causes of death : puerperal from non-puerperal mortality, as 
well as that caused by puerperal diseases from that caused by 
accidents of childbirth. At present the data for doing this 
are lamentably deficient, if not almost altogether wanting. 

One good recorded fact will here be given. Among 
1,929 mothers dehvered at home by Guy's Hospital in 
1869, 5 deaths only are recorded, and none from puerperal 
diseases; 2 were from heart disease, 2 from pneumonia, 
1 from exhaustion. 



OBJECTIONS TO THE DATA. 

The value of the Kegistrar-General's results, and of those 
given by Le Fort, has been called in question by Dr. 
Duncan in his work already cited, partly on the authority of 
certain results of home practice, quoted from Dr. M'Clin- 
tock, who has collected the statistics of 16,774 deliveries 
exclusively from home practice. There were among these 
45 deaths from accidents of labour, 52 deaths from puer- 
peral diseases, and 34 deaths from non-puerperal diseases ; 
giving a total mortality of 131, or nearly 8 per 1,000. On 
considering these figures, the first impression they convey 
is not that either the Eegistrar-General or Le Fort is wrong. 
But it is a very painful impression of another kind altogether. 
One feels disposed to ask whether it can be true that, in the 



10 NOTES ON LYING-IN INSTITUTIONS. 

hands of educated accoucheurs, the inevitable fate of women 
undergoing, not a diseased, but an entirely natural condition, 
at home, is that one out of every 128 must die ? If the facts 
are correct, then one cannot help feeling that they present 
a very strong prima facie case for enquiry, with the view 
of devising a remedy for such a state of things. It 
must be seen, however, that these statistics of home 
practice are as open to the charge of want of accuracy as 
those of the Registrar-General or Le Fort. The question 
can only be settled by enquiry, and by more carefully kept 
statistics of midwifery practice ; but in the meantime here 
are a few facts, kindly placed at my disposal by Mr. Kigden, 
of Canterbury, which are by no means so hopeless as those 
given by Dr. Duncan. 

' An analysis of 4, 1 32 consecutive cases in midwifery oc- 
curring in private practice during a period of 30 years, par- 
ticularly in reference to mortaUty. Eight mothers died : 
three from convulsions and coma ; 4 from puerperal fever ; 
and one from heart disease, about an hour after a compara- 
tively easy labour.' 

The report states 8, but after it was supplied another 
death took place, the day after delivery, making 9 in all. 
The cause of death is not given. 

Mr. Eigden explains that these figures relate only to the 
first fortnight after deUvery ; but he states that if any other 
deaths had taken place within the month, he must have 
heard of them. 

Assuming the Deliveries at 4,133 and the Deaths at 9, 
Mr. Eigden's facts show a total mortality of 2*17 per 1,000, 
of which less than 1 per 1,000 was due to puerperal fever. 



DEATH-KATES IN LYING-IN INSTITUTIONS. 11 



ESTIMATED APPROXIMATE HOME DEATH-RATE. 

In estimating the probable accuracy of statistical data in 
which there may be both excesses and deficiencies, sources 
of error are diminished by largeness in the numbers em- 
ployed in striking averages. Bearing this in mind, and after 
considering the objections brought against the accuracy of 
the figures, there seems no reason for rejecting the Eegistrar- 
General's average total mortality among lying-in women in 
England of 5*1 per 1^000, as affording a sufficiently close ap- 
proximation to the present real death-rate among lying-in 
wotnen delivered at home, for all practical purposes of com- 
parison with the death-rates in lying-in hospitals. 



DEATH-RATES IN LYING-IN INSTITUTIONS. 

We shall next show approximately what are the death- 
rates in estabhshments for lying-in women. 

We will give an abstract of mortality statistics for a number 
of these institutions, the general results of which may be 
stated as follows : — 

In eight military lying-in hospitals (Table IV.), in which 
5575 deliveries took place, in periods of from 2 to 12 years, 
there were 50 deaths (excluding a death before admission) 
— a death-rate of 8'8 per 1,000. 



NOTES ON LYING-IN INSTITUTIONS. 



rn^Ki j- rS'"* 1 |g 1 


1 

■5 




1 1 1^ 1 1 1 1 


^ 


^adiua 


1 1 1 1 1 1-^ 1 


tvfmi 


1 1 M 1 1 1 1 


« 






(N 


BHimn 


1 1 1=^ M 1 1 


- 




1 1 1 1 1 M 1 


- 


saiB)aJOTi>l"a»ai 


1 1 1 1 1^ 1 1 


- 


fmoioioMO 


1 l^-^'^ 1 1 1 


** 


'joasmj 


1 1 1-^ t ( 1 1 


'^ 




1 1 H 1 1^ 1 


« 


mBinpMn^dna 


1 1 1- 1 1 [ 1 


« 




1 1 1^- 1 1 1 


o 




- H-- 1 1 1 1 


M 


inimnng 


1 t 1 1^^ 1 1 


n 




1 l^:^l 1^1 |s 


5l 


§ii|ils^ 


t 


^ 


1 


1 


tllllll 1 



MORTALTTT IN WORKHOUSES. 



13 



In Liverpool workhouse lying-in warcle (Table V.), with an 
approximate number of 6,396 deliveries in 13 years, there 
were 58 deaths from all causes — a mortality of 9'06 per 1,000. 

Table V. — Statiaties of Midwifery Wards m Liverpool Work- 
hcniae for Thirteen Years, 1858-70 indueive. {Abstracted 
from data supplied by Dr. Barnes, Liverpool.') 



Cmiafg of Death 




|s 


li 
II 


1 

1 
1 


ll 


I 

1 
1 


fill 


1 


If 


J 




! 


1 


J 


is 




11 


1 

3 


6,306 


16 


4 


1 1 


& 


5 1 


. 


1 2 


1 


S 


1 


4 


5 


3 


3 


1 


58 



And in 27 London workhouse infirmaries (Table VI.), 
amongst which deaths took place, having 9,411 deliveries 
in five years, there were 93 deaths from all causes. The 
death-rate was 98 per 1,000.^ 

Table "VT. — Mortality after Childbirth i/n Five Tears, up to the 
ejid of 1865, in Forty London Workhouse Infirmaries in 
which Deliveries took place. {Abstracted from, Report on 
Metropolitan Woi'l^iouses.) 



DellTHlfl 


Duthe 
from 


(romA«i- 


B«ths 
from 


Desths 


other 


Totsl 
Sstba 


27wor1thoiiaes: 9,411 
13 „ 2,469 


39 




20 







15 




19 



m 





' In 1868, 69, 70, there were in Liverpool workhouse, 1,416 deliveries, 
including 30 premature, and 6 deaths from all cauaee, of which 3 ttt lenst were 
non-puerpentl. The total death-rate was only 42 per 1,000. There were 13 
London workhouses in which, in 5 years, 3,469 deliferieB, hut no deaths in 
childhed, took place. 



14 



NOTES ON LYING-IN INSTITUTIONS. 



The City of London Lying-in Institution, during ten years, 
1859-1868, had 4,966 deliveries, and 54 deaths — a rate of 
10-9 per 1,000. 

The British Lying-in Institution had 1,741 dehveries, and 
25 deaths, in 11 years, 1858-1868, giving a death-rate of 
14 3 per 1,000 (Table VIH.). 

The mortahty in Queen Charlotte's Lying-in Hospital : 
9,626 deliveries, and 244 deaths, from 1828 to 1868 (Table 
Vn.), was 25-3 per 1,000. 



Table VII. — Mortality in Queen CJiarhMe Lying-4n Hospitalj 

1828 to 1868. 



Deliveries 


Deaths from 

Puerperal 

Diseases 


Deaths from 

Accidents in 

Childbirth 


Deaths from 

Miasmatic 

Diseases 


Deaths from 

Conramptdon 

and Chest 

Diseases 


Deaths from 

aU Other 

Causes 


Total 
Deaths 


9,626 


138 


61 


8 


32 


15 


244 



The Eotunda Hospital, Dublin, with 6,521 deliveries in 
the years 1857-1861, yielded 169 deaths — a death-rate of 
26 per 1,000. But, if we take the years 1828-1861, with 
63,621 deliveries, we find that the deaths were 924, and 
the death-rate only 14*5 per 1,000 — the average annual 
number of deliveries being almost as many thousands as in 
Queen Charlotte's Hospital were hundreds. 



MORTALITY IN LYING-IN INSTITUTIONS. 



15 



Table VIII. — Mortality 'per Thousand frorfi all Gauaea after 
Delivery. {Abstracted from Offi/dal Reports and Returns.) 



Places 



{1861 
1862 
1863 
King's College Hospital, 1862-7 . 
Rotunda Hospital, Dublin, 1857-61 
Queen Charlotte's Lying-in Hospital, 1828- 

68 . . • • . 

British Lying-in Institution, 11 years, 1858 

—68 .... 

Citj^ of London Lying-in Hospital, 1859-68 
8 military lying-in hospitals, 2 to 12 years . 
Liverpool Workhouse Lying-in Wards, 13 

years, 1858-70 . . 

40 London workhouse infirmaries, 5 years 
1 military lying-in hospital (a wooden hut) 

1865-70 . . • . 

All England, 1867 . 



DeUyeries 



7,309 
7,027 
7,289 
780* 
6,521 

9,626 

1,741 
4,966 
5,575 

6,396 
11,870 

252 
708,349 





Deaths per 


Deaths 


Thousand 




DeliTeries 


^^^ 


951 


_ 


69-7 


— — 


70-3 


26 


33-3 


169 


260 


244 


25-3 


25 


14-3 


54 


10-9 


50 


8-8 


58 


906 


93 


7-8 








3,933 


5-1 



* Ezclusiye of a fatal case deliyered in a cab. 



The lying-in wards of King's College Hospital, years 
1862-1867 (Table IX.), gave 27 deaths— a death-rate of 
33-3 per 1,000 on 780 deliveries. 



Table IX. — Mortality after Childbirth in Lying-i/n, Ward, 
King*s College Hospital, 1862 to 1867. 



DeUveries 


Deaths from 

Puerperal 

Dis^uBes 


Deaths from 

Accidents in 

Childbirth 


Deaths from 

Miasmatic 

DLseases 


Deaths from 

Consmnption 

and Chest 

Diseases 


Deaths from 

another 

Causes 


Total 
Deaths 


781* 


23 


1* 





1 


2 


27 



* One deliyery took place in a cab, and the woman died in hoE^pital. 



16 NOTES ON LYING-IN INSTITUnONS. 

Lamentable as are these death-rates in many British 
institutions, they are small in comparison with those which 
have ruled in many foreign hospitals. 

Table X. contains an abstract from Dr. Le Fort's work of 
the statistics of 58 lying-in institutions in nearly every country 
of Europe, and extending in many cases over a considerable 
number of years. There is only one hospital (at Bourg) in 
which there was no death in 4 years, out of 461 deUveries. 

There is one hospital (at Troyes), with a death-rate of 4 
per 1,000 on 460 dehveries in 4 years. 

There are two instances of death-rates of 7 per 1,000. 
There is one of 9, and there are two of 10 per 1,000. 

In every other case the death-rates have exceeded these 
amounts, rising higher and higher in different institutions, 
until they culminate in a death-rate of no less than 140 per 
1,000, at Strasburg, on a four years' average among 556 de- 
liveries. Le Fort's data show a striking variation in the 
death-rates of the same hospitals in different yeaxs, as will 
presently be seen to be the case in hospitals in this country. 
There are instances in these foreign hospitals of the death 
rates varying from 4 to 7-fold in different groups of years 
in the same hospital. 

Le Fort's data show that in lying-in hospitals in various 
countries and climates, scattered over nearly the whole of 
Europe, out of 888,312 dehveries there were no fewer than 
30,394 deaths, giving an average death-rate of 34 per 1,000, 
a rate exceeding the high mortality which led to the dis- 
continuance of our school for training midwifery nurses in 
King's College Hospital. 



MORTALITY FROM ALL CAUSES. 



17 



Table X.^ — Table Showing the Death-rate from all Causes 
amongst Wom^n Delivered in Lying-in Hospitals. (J.6- 
strojCted from Ih\ Le Forts ' Des Matemites.'*) 



Maternity Hospitals 



ft 



Vienna Maternity 

Students* Clinique 

Midwives „ 

Acad^mie Jos^pliine 
Prague Maternity 
Munich 
Gottingen 
Gratz 

Grei&wald Clinique 
Bremen Hospital 
Halle Clinique 

Berlin Clinique de TUniversit^ 
Frankfort-on-Main Maternity 
Leipzig Ancienne ,, 

Nouvelle „ 

Pesth Clinique 
Moscow Maternity de la Maison des 

Enfans Trouy^s 
Ditto • • 

Ditto. 

St. Petersburg Clinique de la Faculty 
Hospital Kalinkin 
Institut des Sages 

Femmes 
Maternity des Enfans 
Trouv^s 
Dublin Maternity 
Ditto. 
Ditto. 
Ditto. 
Ditto. 
Ditto, 
Ditto. 

London Lying-in Hospital 
Edinburgh Hospital . 
Stuttoart fj • 
Zuri(£ Matemitis 
Stockholm y, • 

Gottenburg „ 
Lund fj 

Freiburg en Breisgau 



No. of 

Years of 
Obser- 
ration 



50 

30 

30 

1 

15 

4 

8 

3 

4 

6 

1 

1 

7 

46 

3 

5 

11 
10 
10 
6 
15 

15 

15 
68 
7 
5 
7 
7 
7 
7 
28 
1 
1 
1 
1 
1 
1 
3 



DeUreries 



* 103,731 

104,49^ 

88,083 

^ 277 

41,477 

^ 4,064 

1,029 

3,089 

316 

139 

102 

401 

1,213 

5,137 

594 

2,571 

11,556 

16,72i 

27,759 

' 376 

1,288 

8,036 

16,011 

84,390 

21,867 

12,886 

16,391 

13,167 

13,699 

13,748 

5,883 

277 

424 

200 

650 

223 

33 

28l 





Deaths 


Deaths 


per 
Thoa- 




sand 


2,811 


25 


5,560 


53 


3,064 


34 


24 


86 


1,383 


33 


86 


21 


82 


32 


97 


31 


18 


56 


10 


71 


3 


29 


11 


27 


13 


10 


89 


17 


20 


33 


86 


33 


230 


19 


436 


26 


77Q 


28 


34 


90 


20 


15 


238 


29 


825 


51 


876 


10 


309 


14 


198 


15 


158 


9 


224 


17 


179 


13 


163 


11 


172 


29 


3 


10 


3 


7 


20 


100 


37 


m 


18 


80 


2 


60 


10 


35 



c 



18 



NOTES ON LYING-IN INSTITUTIONS, 




J^na Climque 

Dresden Maternity 

Paris Matemit^ 

Ditto. 

Ditto, 

Ditto. 

Ditto, 

Ditto. 

Ditto. 

Total for ditto 

Paris Clinique de la Faculty 

Ditto. 

Ditto , 

Ditto. • 

Total for ditto 

Paris, St Antoine 

Ditto. 

Ditto. 

Ditto. 

Ditto. 

Ditto. 

Total for ditto 

Paris, H6tel Dieu 

Ditto. 

Ditto. 

Ditto. 

Ditto. 

Ditto. 

Ditto. 

Total for ditto 

Paris, St. Louis 

Ditto. 

Ditto. 

Ditto. 

Ditto. 

Ditto. 

Ditto. 

Total for ditto 

Paris, La Charity 

Lyons „ 

H6tel Dieu 
Bouen H6pital G^n^ral 
Bordeaux Maternity 
Lille . 
Bheims 



4 

51 

8 

10 

10 

10 

10 

10 

5 

63 

6 

10 

10 

5 

90 

9 

10 

10 

10 

10 

5 

54 

8 

10 

10 

10 

10 

10 

5 

63 

3 

10 

10 

10 

10 

10 

5 

58 

3 

4 

4 

4 

4 

4 

4 



306 
15,356 
16,307 
23,484 
25,895 
26,538 
34,776 
25,094 

160,704 

1,654 

9,079 

9,462 

• 4,100 

' 24,295 

28 

32 

129 

788 

2,359 

1,868 

5,204 

833 

658 

1,757 

2,338 

3,012 

11,744 

4,972 

25,314 

4 

128 

1,282 

2,832 

2,736 

7,244 

3,812 

19,038 

648 

3,325 

2,016 

1,275 

714 

683 

646 





DeaCha 


Deatbi 


21 


67 


373 


27 


610 


39 


1,114 


47 


1,293 


49 


1,125 


42 


1,458 


41 


1,296 


51 


1,226 


124 


8,124 


56 


117 


70 


859 


39 


379 


40 


288 


70 


1,143 


47 


5 


178 


15 


468 


20 


155 


65 


82 


134 


56 


110 


58 


349 


e7 


36 


43 


34 


51 


81 


46 


17 


7 


106 


35 


325 


27 


232 


46 


831 


32 








2 


15 


51 


39 


173 


61 


102 


37 


200 


27 


252 


66 


780 


40 


84 


126 


91 


17 


33 


16 


9 


7 


30 


42 


fi5 


35 


15 


23 



MOBTAUTY FEOM ALL CAUSES. 



19 



ICatamlty Hospitals 


No. of 
Tears of 
Obser- 
vation 


Delireries 


Deaths 


Deaths 

Thou- 
sand 


Strasburg 

Grenoble 

Bordeaux, St 

St Etienne , 

Toulouse 

Bourg 

Troyes 

Marseilles 

CMteauroux • 

Amiens , 

Colmar 

Nantes 

Nancy 

Orleans 


Andr^, 






4 
4 
4 
4 
4 

4 
4 
4 
4 
4 
4 
4 
4 
4 


556 
554 
547 
515 
493 
461 
460 
444 
423 
396 
396 
340 
320 
301 


78 
20 

86 

8 

9 



2 

16 

20 

5 

26 

17 

9 

3 


140 

36 

65 

15 

18 



4 

36 

47 

12 

65 

50 

28 

9 


Total fo 


rail ho 


spitals , 


• 


— 


888,312 


30,394 


34 



The absolute loss of life in Parisian lying-in wards has 
been greater than in those of any other capital city. 

This is clearly shown in the 'Statistique m^dicale des 
H6pitaux de Paris,' kindly supphed to me by M. Husson, 
the Director of the General Administration of ' Public Assist- 
ance ' at Paris, of whose many proofs of ability, activity, 
and benevolence, it is not here the place to speak. From 
this the following facts are abstracted. The death-rates are 
therein given for 12 hospitals receiving lying-in cases, only one 
of which, however, is a lying-in hospital (the ' Maison d'ac- 
couchement '), and will be found in Tables XI., XTT., XIII. 

In 1861 the average death-rate in these establishments 
was no less than 95.1 per 1,000, 

In 1862 it was 697 per 1,000. 

In 1863 it was 70-3 per 1,000. 

c3 



20 



NOTES ON LYING-IN INSTITUTIONS, 



Table XI. — Mortality per Thotisand among Lying-m Women at 
the undermentioned Parisian HoapitaJs dAiri/ag the Tear 1861. 
{Abstracted from ' Statistiqne MSdicale des H&pitaux^ 1861.) 





Total 
DeliTeries • 


• Mortality per Thoosaiid 


Hospital 


• 


Non- 
Paerperal 






- 


Paerperal 


Total Deaths 


Hotel Dieii 


1,057 


43-5 


161 


59-6 


Piti6 




468 


72-6 


34-2 


106-8 


Charity . 




263 


154-2 


39-7 


193-7 


St. AntoiDe 




350 


71-4 


34-3 


105-7 


Necker 




234 


29-9 


29-9 * 


.59-8 


Cochin 




56 


142-9 


35-7 ' 


178-6 


Beaujon . 




276 


43-5 


3-6 ' 


47-1 


Lariboisi^ 




782 


691 


15-3 


84-4 • 


St. Louis . 




802 


5^'Q 


13 7 


72-3 


Lourcine . 




41 


24-4 




24-4 


Cliniques . 




875 


75-4 


34-3 


109-7 


Maison d'Accouchements . 


2,115 


99-8 


12-8 . 


112-5 


Total 


» • 


7,309 


75-2 


19-8 


96-1 



Table XII. — MortaUtyper Thousand among Lyin^-in WoTnen at 
the undermentioned Parisian Hospitals duirmg the Tear 1862. 
{Abstracted from ' Statistiqtie MSddcale des Hdpitaux de Parish 
1861, 2, 3.) 





rn^^-oi 


Mortality per Thousand 


Hospital 


Total 
Ddlyeries 




Non- 


Total 






Fnerperal 


Puerperal 


Deaths 


H6tel Dieu *• 


975 


35-8 


9-2 


46-1 


Pitid 




462 


45-4 


10-8 


m'2 


Charity 






270 


62-9 


25-9 


88-8 


St. Antoine 






311 


61-0 


19-2 


803 


Necker 






190 


62-6 


21-0 


73-6 


Cochin 






24 


41-6 


83-3 


124-9 


Beaujon 






257 


38-9 


19-9 


58-8 


Lariboisi^re 






816 


34-3 


13-6 


47-8 


St. Louis 






704 


79-5 


8-5 


88-0 


Lourcine 






46 


22-2 


^^ 


22-2 


Cliniques 






769 


79-3 


14-3 


93-6 


Maison d'Accouchem^its . 


2,204 


63-6 


11-3 


74-9 


Tota 


1 


• • 


7,027 


56-7 


12-9 


69-7 



CAUSES OF MORTALITY. 



21 



Table XIII. — Mortality per Thmisand among Lying^n Women at 
the undermentioned Parisian Hospitals d/uring the Year 1863. 
{Abstracted from ^ Statistique Medicate des Hdpitaux,^ 1863.) 





Total 
BeUveries 


Mortality per Thousand 


Hospital- 




Non- 


Total 






Puerperal 


puerperal 


Deaths 


H6telDieu . . 


* 926 


26-7 


41 


30-8 


La Piti6 




644 


441 


1-8 


460 


ChariW 




• 266 


66-4 


19-6 


86-9 


St. Antoine . 




410 


63-4 


11-6 


780 


Necker 




. 232 


38-8 


21-6 


60-3 


Cochin 




68 


736 


14-7 


88-2 


Beaujon 




313 


19-2 


12-8 


31-9 


Lariboisi^re . 




870 


310 


9-2 


40-2 


St. Louis 




871 


23 


9-2 


321 


Lourcine 


■ 


43 


27-9 


— ~ 


27-9 


Clinique 




761 


30-6 


186 


49-3 


Maison d* Aceouchements • 


2,006 


130-1 


7-4 


137-6 


Tota] 


I 


7,289 


60-6 


9-7 


70-3 



CLASSIFICATION OF CAUSES OF MORTALITY IN 

LYINO-IN INSTITUTIONS. • 

The next thing is to endeavour to show to what causes 
these death-rates are to be attributed. Unfortunately Dr. 
Le Fort's tables do not enable us to distinguish the causes 
of death. But the data suppUed by British and Parisian 
hospitals allow the causes to be classified to a certain extent 
under the heads adopted by the Eegistrar-General in his 
Eeports. 

A classified arrangement of this kind is given in Table IL, 
and may be resumed, with the view of showing the enor- 
mous differences in death-rates among puerperal women 
under different conditions, as follows : — 



— > 


— > 


4*9 


3'4 


2-2 


5-6 


41 


21 


6-2 


3-9 


' 3-4 


7-3 


14-3 


5-3 


19-6 


29-4 


none 


29*4 


— 


— 


76-2 


—1. 


— 


66-7 


.^ 


^^ 


eo-6 



22 NOTES ON LYINO-IN INSTITUTIONS. 

Mortality per lyOOO. 

Puerperal AoddentB of and'adtsklraits o< 
dhoMOi ohfldUrtli olilttdrtb 

AH England, 13 yean . • • 1-61 3-22 4-83 

England (healthy diatriets); 10 years, 

312,402 deHveries . . . • — — 4-3 

England, 11 large ioyniB, 10 years, 

1,402,304 deliyeries 
Liverpool workhouse • 

27 London workhouses haying deaths 
8 military female hospitals . 
Queen Charlotte's Lying-in Hospital 
King's College Hospital lying in ward 

r 1861 
12 Parisian hospitals 4 1862 

11863 

We have already seen, as a result of Dr. Le Eort's tables, 
that the mortality among women delivered at home, as de- 
duced by him, is 4*7 per 1,000 ; while in the hospital it is 34 
per 1,000, or nearly 7^-fold. Making any reasonable allow* 
ance for inaccuracy in the data, still we can hardly escape 
from his conclusions any more than we can rid ourselves from 
the consequences which follow from the data given above. 
We must confront the question called up by the data takeii 
as a whole, viz.. What can be the reason of this ascending 
scale of fatality shown on Table ViU. ? Why is it that 
these death-rates from all causes in childbirth, beginning 
at 5*1 per 1,000 for all England (town and country)^, 
successively become, among the same people 9*, 10*9, 14-3, 
25*3, 33*3 ; and if we cross the channel, why should they 
mount up to 69, 70, and 95 per 1,000 ? 

Again, why should fevers and inflammations of the 
puerperal class, which, as we have seen above, give a death- 



INFLUENCES ON THE DEATH-BATE. 23 

rate for all England of 1*61 per 1,000, mount up in English 
hospitals to 3*4, 4-1, H'S, and 29*4? There must be some 
reason, besides the fact of childbirth, why diseases and 
accidents of this condition should be 4 times more fatal in 
a London lying-in hospital, and 15 times more fatal in 
Parisian hospitals, than they are in towns of England. What, 
then, are the immediate causes of these excessive death- 
rates? 



CAUSES OF HIGH DEATH-RATES IN LYING-IN 

INSTITUTIONS. 

The determining causes of these death-rates need to be 
discussed most cautiously; — our information concerning 
them being so scanty. 

We know from Statistics that these Deaths occur, but 
why they occur and why they vary are questions not yet to 
be fully answered in our present stage of knowledge (or of 
ignorance). 

At one time a suflScient cause seems to present itself; but 
the very next outbreak of Puerperal disease may occur 
imder quite different conditions. For years an Institution 
may escape excessive Mortality; and then it may suffer 
severely under the same apparent circxmistances. All that 
we can do at present is to see whether there are removable 
causes in cases where the Mortality is excessive, and to 
remove them. Fully recognising how much we have need 
ot caution, this subject will be next considered generally 



24 NOTES ON LYING-IN INSTITUTIONS. 

and as far as possible in its practical bearings on the points 
at issue. 

There are some important remarks in Dr. Le Fort's book, 
bearing on this subject, which may find a place here. 

Puerperal Fever. — Dr. Le Fort states, as the result of his 
enquiry, that the frequency of obstetrical operations modifies 
the general mortality only in a slight degree ; that the ex- 
cessive mortaUty in lying-in hospitals is much greater than 
can be attributed to ordinary hospital influences ; that it 
depends neither on the social condition of the women, nor 
on the moral conditions under which delivery may occur ; 
that it may be more or less influenced by the insalubrity of 
particular hospitals, but that puerperal fever is the principal 
cause of death after delivery ; that this disease shows itself 
m all hospitals, in all maternity institutions, in all climates, 
in the south of France as it does at St. Petersburg, in 
Dublin as in Vienna, in London as in Moscow. It exists in 
America as in Europe. 

It is less frequent and fatal during the summer months, 
attributable in part at least to greater facihties of ventilation 
following on higher temperature (in other words, to having 
your windows open instead of shut). 

This disease develops itself spontaneously imder certain 
unknown circumstances. When it is about to become 
epidemic, it is sometimes preceded by the prevalence of 
erysipelas. 

Dr. Le Fort points out that what was considered a severe 
epidemic in the British Lying-in Hospital, in the year 1770, 



INFLUENCES ON THE DEATH-RATE. 25 

is ' unfortunately less than the mean mortality of the Ma- 
ternity at Paris/ 

While admitting that puerperal fever may originate de 
novo^ Dr. Le Fort dwells strongly on the communicabihty 
of the disease as an efficient cause of its prevalence. 

He adduces opinions of the following physicians — Op- 
polzer, Eokitansky, and Skoda, of Vienna ; Virchow, of 
Berhn ; Lange, of Heidelberg ; Schwarz, of Gottingen ; 
Loschner, of Prague ; and Hecker, of Munich — on the nature 
and origin of this fatal disease. Generally they testify to 
the propagation of puerperal fever by contagion, but they 
also state that it is a blood disease — a product of foul air, 
putrid miasms, and predisposition to malignant inflammatory 
action. 

Dr. Le Fort also cites a number of interesting facts, 
showing that the indiscriminate visiting by attendants of 
lying-in women and patients suffering from disease, either 
within or outside the same establishment, has been a means 
of exciting puerperal fever action. 

Admission of Students. — It is one of the contingencies 
necessarily due to connecting together the teaching of mid- 
wifery to students, with other portions of cUnical instruction, 
that no precautions can prevent a student passing from a 
bad surgical case, or from an anatomical theatre, to the 
bedside of a lying-in woman, while sad experience has 
proved that the most fatal results may ensue from this cir- 
cumstance. 

Of course risks of this kind are greatly increased when 



26 NOTES ON LYING-IN INSTITUTIONS. 

there are lying-in wards in general hospitals — especially 
if a medical school be attached to such a hospital 

This risk had not been overlooked in the arrangements 
for the lying-in wards at Bang's College Hospital, under 
which, while intended solely for the training of midwifery 
nurses, provision was made for a limited and regulated 
attendance of students ; but, when enquiries came to be 
made into the probable cause of the high death-rates, it was 
found that the restrictions laid down as to the admission of 
students had been disregarded ; also that there was a post- 
mortem theatre almost under the ward windows. 

Effect of Numbers. — Dr. Le Fort has examined the in- 
fluence exercised by numbers — or, in other words, by the 
size of hospitals — on the mortality after childbirth. His 
general results may be briefly stated as follows : — 

In hospitals receiving annually more than 2,000 lying-in 
cases, comprising the two Cliniques of Vienna, 1834-63 ; the 
Maternit^s of Paris, 1849-59 ; of Prague, 1848-62 ; and 
of Moscow, 1853-62 ; and the Lying-in Hospital of Dublin, 
1847-54, the death-rate is 40-7 per 1,000. 

In hospitals receiving between 1,000 and 2,000 cases a 
year, including the Enfans Trouv^ at Petersburg, 1845-59 ; 
the Maternity at Munich, 1859-62, and other places, the 
death-rate is 36 per 1,000. 

In hospitals receiving from 500 to 1,000 cases a year, 
including Pesth and the Maternity of Dresden, the death-rate 
is nearly 27 per 1,000. 

In hospitals where the number of deUveries is between 
200 and 500 per annum, comprehending several places 



EFFECT OF NUMBERS. 27 

cited, among the rest Edinburgh and the London Lying-in 
Hospital, 1883-60, the death-rate is SO^ per 1,000. 

In hospitals receiving between 100 and 200 cases, as 
at Frankfort and Gottingen, the death-rate is 27*6 per 1,000. 

And in three small establishments receiving fewer than 
100 a-year, as at Lund, the death-rate is above 83^ per 
1,000. 

From these facts Dr. Le Fort concludes that the relative 
mortality in small and large establishments is not favour- 
able to smaU hospitals, per se. The benefit of subdivision 
may be neutralised by other circumstances. 

We must also protest against massing hospitals, alike only 
in one circumstance, together for the sake of taking their 
statistics in bulk in this way, except for the most general 
purposes — ^which is indeed all Dr. Le Fort has in view here 
— especially as our own lying-in institutions of these islands, 
which come out best individually, appear here confounded 
amongst the greatest sinners. But Dr. Le Fort's general 
conclusion, against the influence of Bize per se, is no doubt 
correct. 

As a general rule, statistics appear to show that the great 
mortality of lying-in hospitals is of periodical occurrence. 

Puerperal women, as everyone knows, are the most 
susceptible of all subjects to * blood-poisoning.' The smallest 
transference of putrescing miasm from a locality where 
such miasm exists to the bedside of a lying-in patient is 
most dangerous. Puerperal women are, moreover, exposed 
to the risks of ' blood-poisoning ' by the simple fact of being 
brought together in lying-in wards, and especially by being 



28 NOTES ON LYING-IN INSTITUTIONS. 

retained a longer time than is absolutely necessary in lying- 
in wards after being delivered, while to a great extent they 
escape this entire class of risks by being attended at home. 

There are no doubt difficulties in assigning the exact 
effect of every condition to which a lying-in woman may 
be exposed in contributing to these death-rates, but there 
are, nevertheless, a few great fundamental facts which arrest 
attention in such an enquiry. 

It is a fact, for instance, that however grand, or however 
humble, a home may be in which the birth of a child takes 
place, there is only one delivery in the home at one time* 
Another fact is, that a second delivery will certainly not 
take place in the same room, inhabited by the same couple, 
for 10 months at least, and may not take place in the same 
room for years. The Eegistrar-General has shown us that 
under these conditions the death-rate among lying-in women 
all over England, and from aU registered causes, is about 
5-1 per 1,000. 

In many London workhouses the number of deliveries 
yearly is so small that, so far as concerns annual deliveries, 
they approach more closely to dwelling-houses divided 
among a number of families than they do to lying-in 
hospitals properly so called. 

Let us now see what relation there is between the annual 
deliveries and the death-rates in these workhouse wards. 

Assuming that the London workhouse lying-in wards 
have certain conditions in common, we find that twenty- 
seven infirmaries suffered from lying-in deaths in five years, 
and that in thirteen there were no deaths in the same 



WATERFORB LYING-IN INSTITUTION. 29 

years. Now, in eacli of these twenty-seven hospitals 
yielding deaths, the deliveries averaged 29 per annum, 
while in the thirteen infirmaries without deaths the de- 
liveries averaged under 16 per annum. 

Again, in twenty-one infirmaries with deaths, the average 
disposable space for each occupied lying-in bed was 2,246 
cubic feet ; while in nine infirmaries without deaths the 
space per occupied bed averaged 3,149 cubic feet. These, 
however, are only averages, and as such may be taken for 
what they are worth. There were exceptions to these 
rules in particular cases. 

The facts regarding Waterford Lying-in Institution have 
a very important bearing on this question of subdivision. 

In the years from 1838 to 1844 this hospital consisted of 
two rooms in a small house. One room was a dehvery 
ward. The other held eight lying-in beds. The total 
deliveries in this house amounted to 753, and there were 
6 deaths =8 per 1,000. Half this mortahty was due to 
puerperal fever. 

In October 1844 this hospital occupied another small 
house, in which the eight lying-in beds were placed in two 
rooms instead of one as formerly — four beds per room. 
Up to October 1867 there had been 2,656 deliveries in this 
house, and 9 deaths — a mortality of 3*4 per 1,000. 
There were only two puerperal fever deaths in these 2,656 
deliveries. 

These facts appear to show that subdivision among lying- 
in cases has a certain influence in warding off mortality. 

But, on the other hand, the death-rates among lying-in 



80 NOTES ON LYING-IN INSTITUTIONa 

cases in particular hospitals are not always in the ratio of 
the number of occupied beds. A few illustrations of this 
will suffice. 

Thus, in the year 1861, there were in the Botunda 
Hospital, Dublin, 1,135 deliveries, on which the death-rate 
was 51'9 per 1,000. In 1828 the deUveries were 2,856, 
and the death-rate 15 per 1,000. In the four years 
1830 to 1833, the deliveries varied from 2,138 to 2,288, and 
the death-rates were a Uttle more than 5 per 1,000. In 
Queen Charlotte's Hospital the highest death-rate occurred 
in 1849, during which year there were 161 deliveries. 
The death-rate was 93*2 per 1,000, while in 1832, with 
217 deliveries, the death-rate was just one tenlJi of this 
amount. 

In the Maison d'Accouchement at Paris, during the five 
decennial periods between 1810 and 1859,^ there were 
141,476 deliveries, among which there occurred 6,288 
deaths, giving a death-rate of 44*4 per 1,000. The lowest 
death rate in any of the decennial periods occurred 
between 1840 and 1849, when it amounted to 41*9 per 
1,000. The largest number of deliveries of any period in 
the half century was during this ten years. They amounted 
to 34,776 ; while, in the period from 1850 to 1859, the 
deliveries were 24,944, and the death-rate 52 per 1,000. 

The Dublin Eotunda approximates most to this Paris 
Maternity in the large number of deliveries, vibrating 
around 2,000 a year ; while, in Queen Charlotte's Hospital, 

* Husson, ' fitude sur les H6pitaux/ p. 254. 



CAUSES OF MORTALITY. 31 

wtere, even since its reconstruction, the mortality has been 
in many years higher than in the Dublin Eotunda, the 
number of annual dehveries has varied around 200. 

Danger of Puerperal Epidemics. — ^These facts have a 
very important bearing on the whole question of lying-in 
institutions, for they show that, with scarcely an exception, 
while the lowest death-rate in any given year greatly 
exceeds the average mortality among lying-in women 
delivered at home, the • inmates of these institutions are 
exposed to the enormous additional risk of puerperal 
epidemics. 

Take, for instance, Queen Charlotte's Hospital. There is 
no reason to believe that less care and solicitude for the 
welfare of its inmates is exercised than would be the case 
if they were delivered at home. And yet we find that 
year by year, from 1828 down to the present time, the 
institution has only escaped deaths for four years. The 
lowest death-rate it ever had was in 1835, when it 
amounted to 4*6 per 1,000. In other years it has been 
11, 15, 21, 30, 50, 70, 81, 86, and in one year it rose to 
the immense death-rate of 93*2 per 1,000. 

In 1849 there were, as above said, 161 deliveries out of 
which fourteen women died from puerperal fever, being a 
death-rate of 87 per 1,000 from this disease alone. 

The statistics of other lying-in institutions afford cor- 
responding data. It is a lamentable fact that the mortality 
in lying-in wards from childbirth, which is not a disease, 
approaches closely to the mortality from all diseases and 
accidents together in general hospitals, and in many 



32 NOTES ON LYING-IN mSTITtTTIONS. 

instances even greatly exceeds this mortality. It is the 
more lamentable, because, as need scarcely be stated, the 
causes of a higher mortahty in infancy and old age cannot 
exist at child-bearing ages. Also, childbirth ought cer- 
tainly not to be a ' miasmatic disease.' Unless, then, it 
can be clearly shown that these enormous death-rates can 
be abated, or that they are altogether inevitable, does 
not the whole of the evidence with regard to special 
lying-in hospitals lead but to one conclusion, viz. that they 
should be closed? Is there any conceivable amount of 
privation which would warrant such a step as bringing 
together a constant number of puerperal women into the 
same room, in buildings constructed and managed on the 
principles embodied in existing lying-in institutions ? 

Fatality of Lying-in Wards in General Hospitals Be- 
sides special lying-in hospitals, there are general hospitals 
which receive lying-in cases. Fortunately, there are not 
many such in England. But in Paris there are 11^ general 
hospitals which receive midwifery cases. A reference to 
Tables XL, XII., XIII., will show how great the risks are 
to lying-in women under the same roof with medical and 
surgical cases ; a fact which may be further illustrated by a 
reference to data for particular hospitals. For example, in 
1861, 253 lying-in cases in La Charity gave a total death- 
rate of 1937 per 1,000, of which no less than 154-2 was 
due to puerperal causes. These tables tell their own story, 

^ Tables XI.^ XII., XIII.^ abstracted from tbe ^ Statistique m^dicale des 
H6pitaux de Paris.' 



INFLUENCES OF CX)NSTIlUCTION AND MANAGEMENT. 33 

and they throw altogether into the shade the lamentable 
losses at King's College Hospital. 

The only amende that could be made was to shut up the 
ward ; and having done this in the interest of womankind, 
need it be said that the impression produced by these 
statistics confirms the conclusion just stated in regard to 
existing lying-in wards generally, and is that not a single 
lying-in woman should ever pass within the doors of a 
general hospital ? Is not any risk which can be incurred 
outside almost infinitely smaller ? And as a general hos- 
pital must always be a hospital, must not this verdict be an 
absolute one, not one which can be altered or reversed ? 



INFLUENCE OF CONSTRUCTION AND MANAGEMENT OF 
LYING-IN WARDS ON THE DEATH-RATE. 

Before, however, surrendering entirely the principle of 
special lying-in institutions, it is only fair to enquire whether 
the construction, management, and arrangements of existing 
hospitals of this class may possibly have had any influence 
upon the mortality, apart from the mere fact of bringing 
lying-in cases together under one roof. 

This question is the more important because we now know 
that construction and arrangement of buildings exert a 
notable effect on the death statistics of general hospitals. 
It is at last universally admitted that airy open site, simpli* 
city of plan, subdivision of cases under a number of separate 
pavilionSj large cubic space, abundant fresh air, mainly from 
windows on the opposite sides of the wards, drainage arrange- 

D 



34 NOTES ON LYING-IN INSTITUTIONS. 

ments entirely outside the hospital, are essential conditions 
to the safety of all general hospitals. But, as already stated, 
it is likewise admitted that lying-in women are peculiarly 
susceptible to ' blood poisoning.* 

This being the case, have we any reason to expect other 
than a high death-rate if we collect lying-in women into 
such wards, or rather rooms, as are found in many old hos- 
pitals ? 

Nobody with ordinary knowledge of the subject, and 
desirous simply of benefiting suffering people, would now 
dream of appropriating buildings of this kind as hospitals 
for sick. But it is to be feared that the same scruple 
has not always existed with r^ard to lying-in women. 
And as we now know that such buildings give high death- 
rates among sick and wounded people, there is every reason 
to fear that they have had their share in raising the death- 
rate among lying-in women to a greater extent than that 
due merely to the fact of agglomeration. As instances of 
the existence of danger from such causes, and also from 
grave errors in administration, two or three illustrations 
are here introduced from existing lying-in establishments. 

Matemite^ Paris, — ^We have seen from the statistics that 
the chief of chief offenders in times past has been the 
Maternity at Paris. This estabhshment was in former 
times the monastery of ' Port Eoyal de Paris." It is situ- 
ated in one of the most healthy open spots on the outskirts 
of the French capital, and, as far as situation is concerned, 
ought to be healthy. The building was devoted to its 
present destination in 1795, and has undergone many 



mateiinit:^, paris. 35 

changes since that date. It contains 228 beds for lying-in 
women, and, besides, accommodation for 94 pupil midwives. 
From 1,000 to 2,200 deliveries and upwards take place 
here annually : from 1840 to 1849 there were as many as 
3,400 annually. Until recently it consisted properly of three 
divisions, delivery wards, ceUs for delivered women in the 
process of recovery, and an infirmary. 

The delivery ward is well lighted on two sides, and com- 
municates with an operation theatre, where lectures are also 
given. 

The woman, if progressing favourably after deUvery, 
was removed to one of the cells in what may be called the 
recovery ward. The construction of these cells was as 
follows : — a long corridor, with windows on opposite sides, 
was divided into separate ceUs, each cell having its own 
window, by partitions stretching one third across the 
corridor, but not cut off on the end towards the middle of 
the corridor. Each cell was provided with a bed and a 
cradle, so that in walking up the centre of the corridor the 
divisions, or rather the cells, opened right and left from the 
passage, like the stalls of a stable. This construction 
rendered it almost impossible to open the windows. The 
infirmary consisted of small wards of three or four beds 
each, into which were moved indiscriminately patients 
suffering with all classes of disease. And it appears, from 
Dr. Le Fort's account, that pupil midwives had at the same 
time patients in the infirmary, and heallliy women, both 
delivered and not delivered, under their care. Pregnant 
women are often admitted weeks, and even months before 

9 2 



36 NOTES ON LYING-IN INSTITUTIONS. 

delivery, at the Maternity. [So also at the Midwives*' 
Cliaique at Vienna.] 

Becently the cells have been removed fix)m the corridor, 
and glass partitions have been thrown across from back to 
front, each division containing six beds, but commimicating^ 
with the adjoining divisions by means of doors intended to 
be used only when the service requires it. 

The infirmary has been completely separated from this 
portion of the establishment, but all classes of cases are 
stiU transferred into the infirmary as before. 

As cc^uenc. of .h«e ar^en,^, we have in the 
Maternity the following conditions ! — 

1. The agglomeration of a number of lying-in women 
under the same roof. 

2. An internal construction of the building not suited to 
give fresh air, to say the least of it. 

3. The infirmary until recently connected with the other 
portions of the building, and even now receiving all classes 
of cases among lying4n women, whether febrile or not, for 
treatment. 

4. One class of attendants devoted indiscriminately to all 
classes of inmates. 

5. As already mentioned, women admitted and retained 
within the walls of the estabUshment before and after the 
time simply required for deUvery and convalescence. 

Lastly, an enormous death-rate mainly from puCTperal 
diseases, 

Edpital de la Clinique^ Pam.— This establishment is part 
of the hospital for clinical instruction, close to the buildings 



CLINIQUE, PAEIS. 37 

of the ficole de M^decina The hospital consists of a paral- 
lelogram with a central court, containing not only the 
chnical surgery wards, but also an amphitheatre devoted to 
anatomical studies, with a mean number of fifty corpses in 
the course of dissection. 

There are six wards devoted to the midwifery depart- 
ment, arranged in ft complicated ^manner^ partly across 
the corridor, and partly on each side of the corridor, all 
of them entered from a central passage lighted by the 
open doors of the wards along the sides. They contained 
54 lying-in beds. From 800 to 900 deliveries took place 
here annually. 18 to 20 days appear to be the average 
stay. The beds must, therefore, have been pretty constantly 
full. 

The wards devoted to women who have been delivered 
communicate freely with one another by open doors. The 
beds are curtained, and the curtains are washed only once 
in six months, even though the occupants of the bed may 
have died of puerperal fever. The beds are of iron, and are 
provided with a spring mattress, over which is a wool 
mattress. The latter is removed after each delivery, 
cleansed, and renewed. There is no infirmary for diseases ; 
whether cases of puerperal fever br others, all are treated 
in the beds in which they are placed after delivery. 

The female staff performs its duty to all classes of cases. 

Students entered upon the roll for midwifery practice 
are called into the wards from other parts of the estabUsh- 
ment by signals placed in a window. 

It is quite unnecessary to search for any more recondite 



38 NOTES ON LYING-m INSTITUTIONS. 

causes of the past excessive mortality of this establishment 
than these simple &ct3. 




The above plan, taken from M. Husson's 'Etude sur 
les H6pitaux,' will show the arrangement of wards and beds 
in this place. [Dr. Le Fort says that the number of beds 
in each ward has since been reduced by a third.] 

^ieen Charlotte's Lying-in Hospital, London. — Plate I. 
shows a plan and section of Queen Charlotte's Hospital, as 
rebuilt in 1856. 

On each floor are 6 wards, containing 3 beds each, in 
which the patients are delivered, with an average of 1,000 
cubic feet to each patient. On each floor, also, is one con- 
valescent ward, containing 6 beds. Two floors are devoted 
to patients : one for married, and one for single women. 
As soon as 3 patients have been delivered in a ward, it 
remains vacant for 8 or 10 days, and is cleansed. Patients 
are removed as soon as possible to the convalescent ward. 







S ECTION . 
Quetrt/ Otorlettx^ Lyinq in/ HospttoU/. 



1 




n 


1 = 








Ft 1 D O B ■ = 




•"vr 1 1 v"5 ' 


a>IE6 ■■ CONVALCSCEMT W*HD 

1 ^^-'^^ 













First floor Plan. 



QUEEN CHARLOTTE'S HOSPITAL. 39 

When a case of fever occurs, the ward is freshly white- 
washed, and not occupied again for at least a month. 

In this building we have three floors and a basement. 
A drain runs from back to front of the building, right across 
the basement — a most unsafe course for a drain in any in- 
habited building.* 

It will be seen that the rooms are placed on opposite 
sides of a main corridor running the lengthway of the 
building on each floor ; that the corridors of the different 
floors communicate by the stairs ; that the ventilation of 
each room communicates with the ventilation of every other 
room through the corridors ; that none of the rooms have 
windows on opposite sides, and that there are water-closets 
having a ventilation common to that of the building. Now 
every one of these structural arrangements is objectionable, 
and would be considered so in any good hospital, and 
nobody now-a-days woidd venture to include all of them in 
a general hospital plan. They are hence a fortiori altogether 
inadmissible in a building for the reception of lying-in 
women. 

We have thus, in Queen Charlotte's Hospital, the fol- 
lowing defects : — 

1. Agglomeration of a number of cases under the same 
roof. 

2. A form of construction unsuited for hospital pur- 
poses. 

3. No means of removing outside the building febrile 
or other cases of puerperal diseases from the vicinity of 
patients recovering after delivery. 

^ This drain was shown on the Plan from which Plate I. is taken. 



40 



NOTES ON LYINCt-IN mSTETUTIONS. 



Since 1856, notwithstanding the great improvements, the 
death-rates per 1,000 have been 12-2, 8-8, 81-2, 70-3, 54-2, 
89'2, 15*6, and so on : in several years very considerably 
larger than the mortahty which led to the clofdng of the 
lying-in wards in King's CoUege Hospital. These varying 
deaths lead to the exercise of much caution in drawing con- 
clusions as to their causes ; but the main fact remains, namely, 
there are the death-rates, and they are many times greater 
than occur among London poor women deUvered at home. 

Midwifery Wards, King's College Hospital. — ^The follow- 
ing plan shows the provision which existed for training 
midwifery nurses at King's College Hospital 




J, A, Accouchement Wards, used ol- 
temaUl;. 

B. Kecovery Ward. 

C. Contcuna Linen PresBei, and In- 

fonts' Baths, &c., for Ward 

D. Superior's Bed-room. 
K Midwife's Iloom. 

F. Port-moWeiu Theatre. 
C, G, GeDentl and Fnrision Boiata. 



K. This toot is not higher than 

the basement. 
X . Ventilating openings on & 
lerel with npper part of 
oppo site window. 
a, a, a, a. Boors cutting off commiuiica- 
Uon with either Accoi)ch&- 
ment Ward when ueceesai;, 
4. Ko. i Warf. 



MILITARY FEMALE HOSPITALS. 41 

The plan shows the relation of the deUvery wards to the 
recovery ward, and to the other parts of the hospital ; to 
the lecture room, post mortem theatre, &c. The main defects 
in the construction are : the back to back wards ; proximity 
of these wards to the general wards of the hospital ; the large 
staircase, common to both sets of wards, although its size 
and openness, and the windows opposite each other and on 
each floor, ensured ventilation, and separated the respective 
blocks ; the position of the post-mortem theatre, the smell 
from which, as stated on the best authority, could be dis- 
tinctly detected in the wards. As already stated, students 
were admitted from other parts of the hospital to the mid- 
wifery wards. 



RESULTS OF IMPROVED LYINO-IN WARD CONSTRUCTION. 

A few instances of improved lying in ward construction, 
together with the death-rates in these estabhshments, will 
next be given. 

Military Female Hospitals. — These buildings vary in con- 
structive arrangements. Some are much better than others, 
and during recent years lying-in wards of improved con- 
struction have been provided in connection with several 
newly erected military female hospitals. The earUer plans 
of the new female hospitals consist of a block formed of two 
pavilions joined end to end, with a passage across the block 
to separate the pavilions from each other. Each pavilion 
contains a single ward, with its own separate offices and 
nurses' rooms. It has windows on opposite sides, with one 



42 NOTES ON LYING-IN INSTITUTIONS. 

large end window, and abundant means of warming and 
ventilation. One pavilion is devoted to general cases, the 
other to lying-in cases. 

The midwifery ward has space for twelve beds. Each 
bed has a superficial area of ninety square feet, and a cubic 
space of 1,350 feet. The wards are fifteen feet high. 

Two hospitals on this plan have been in use at Woolwich 
and Chatham for upwards of six years. During this period 
there have been at the two 1,093 deUveries, and 11 deaths. 
At Chatham there was one accidental death from removal 
of the patient to hospital, and out of 342 deUveries there 
have been no deaths from puerperal diseases. There were, 
however, two deaths from scarlet fever, occurring while 
this disease was prevalent in soldiers' famiUes in the garrison. 
At Woolwich, among 751 deliveries, there have been 8 
deaths, of which five were from puerperal diseases, but of 
these five deaths one took place in a woman who had 
gastric fever at the time of admission, and in other two 
women puerperal peritonitis came on after instrumental 
dehvery. There was one death from embolism, one from 
exhaustion, and one from dropsy. The total death-rate in 
these two hospitals has been under 10 per 1,000. The 
deaths due to diseases and accidents of childbirth have been 
6, or at the rate of 5^ per 1,000. 

Of the other miUtary hospitals, the statistics of which are 
given in Table IV., Devonport and Portsmouth are un- 
suitable adapted buildings. Aldershot Hospital consists of 
a number of huts joined together as a general female hos- 
pital, with accommodation for all kinds of cases, including 



MILITARY FEMALE HOSPITALS. 



43 



lying-in cases. This arrangement is a very undesirable one, 
and the results have been unsatisfectory. 

Table XTV. shows that the total mortality in this hospital 
has been lO'l per 1,000. Of the total deaths 27 are 
attributed to diseases and accidents of childbirth, afford- 
ing a mortality of 8-8 per 1,000, or double that of the 
healthy districts of England. 

If we exclude Aldershot as being unfit for child-birth cases, 
we find that in the other seven hospitals the total mortality, 
as shown in Table XIV., has been 7'4 per 1,000. The mor- 
tality from puerperal diseases in these hospitals has been 
2'7 per 1,000, and from diseases and accidents of childbirth 
6-4 per 1,000. 



Deatha 
per 1,000 
deliveries 



Sal 1 83 e \ % 

llljli I ill 



OOnrWomen'B rio^itals. 



aS\ 's'S 

li.'lll 



4-9;3-0 8'8 1-3 



111 



There are two camp hospitals for lying-in cases, consisting 
only of wooden huts, appropriated for the purpose, which 
have yielded very important experience. One of these is at 
Colchester, the other at Shomcliffe. 

The Shomcliffe Hospital is an old wooden hut of the 
simplest construction, with thorough ventilation. It is 
situated on a rising ground close to the sea, and feeing it, 



44 NOTES ON LYING-IN INSTITUTIONS. 

SO that the sea breeze sweeps right through it. It is scarcely 
more than a makeshift. And here are the results. 

Table IV. shows that up to December 1869, there had 
been 702 dehveries in the hut, among which there was one 
death from scarlet fever, and one from haemorrhage, besides 
two deaths following on craniotomy. There was not a 
single death from any puerperal disease. 

Colchester Lying-in Hospital, of which a plan and sectioH 
are given on Plate II., is nothing more than an ordinary 
officer's wooden hut, divided by partitions into four com- 
partments, with a transverse passage cutting them off from 
each other. This hut has been in use for a considerable 
number of years as a place of lying-in for soldiers' wives 
living in the camp, and there have been altogether between 
500 and 600 dehveries in it. The matron states that 
during the whole time the hut has been in use for its present 
purpose, no death has taken place in it. But as statistics 
have only been kept since 1865, we shall hmit our attention 
to them. They show that, up to the end of October 1870, 
there had been 252 registered deliveries, and no deaths. 

The results of these two makeshift hospitals, when com- 
pared with the figures already given for lying-in establish- 
ments generally, are certainly remarkable. They are both 
detached buildings, having no connection with any general 
hospital. Their construction ensures a plentiful supply of 
fresh air at all times. They contain very few beds, and 
these beds are occupied, seldom or never, all at one time. 
Indeed, it is stated that in the Colchester hut there is 
scarcely more than one, or at most two beds, constantly 




Section on Line A.B. 



•fcalb sf Itttf 




Plan of Wooden Lvinc in Hut 
Colchester camp. 



' . T<p^ air aiAtUtJ - , 



MILITAItY FEMALE HOSPITALS. 



45 



occupied throughout the year. Also, soldiers* wives lying- 
in rarely remain more than ten days, though sometimes 
twelve in hospital. There is, therefore, no crowding; 
scrupulous cleanliness is observed; there are no sources 
of putrid miasm in or near the lying-in huts ; and they 
have their own attendants. The data in Table IV. show 
that there have been 954 registered deliveries in the two 
huts, and four deaths, of which three were due to puer- 
peral accidents, and none to puerperal diseases. 




^■' " " 'caZ '^ ^ * ^ 



A. Wards. 


F. Linen. 


L. Medical ComforttL 


B. Spare Wards. 


a. Batha. 


M. Store. 




H. Eitcheo. 


H. CoaU 


D. Nnraes. 


I. Cook'B K»om. 




E. Lavatoriee. 


K. Store. 





Proposed new Female Hospital at Portsmouth. — When 
military female hospitals were first designed, it was intended 



46 NOTES ON LYING-IN mSTTTUTIONS. 

that they should receive only lying-in and general cases 
from married soldiers' families in separate pavilions. But 
at a subsequent date zymotic cases were admitted into the 
same pavilion with general cases. Very decided objections 
were, however, urged against this step by medical officers, 
and the next hospital planned was divided into three distinct 
pavilions. It was intended for Portsmouth garrison, and is 
shown in the annexed figure. 

A female hospital on this plan has been erected at Dublin, 
with the two end wards bmlt in the line of the corridor 
beyond the ends of it, in place of at right angles to the cor- 
ridor, as shown in the proposed Portsmouth plan. By this 
form of construction the cases received from soldiers' fami- 
lies can be divided into three classes : general, infectious, 
and midwifery — each class in its own separate building. 
Such, however, has been the feeUng of medical officers as to 
the undesirableness of trusting even to this amount of separ- 
ation, that at Dublin the ' infectious ' cases have been re- 
moved to another locality altogether. The same separation 
had been already effected at Chatham and Woolwich. 

Close observation of lying-in cases has led to further 
change in the construction, and it is now proposed to adopt 
for lying-in wards in female hospitals a different form of 
arrangement altogether : namely, to divide the lying-in 
paviUon into separate one-bed rooms, as shown on Plan IV. 

The experience of these small military female lying-in 
hospitals has shown the favourable effect of simplicity of 
construction, plenty of space, light, and fresh air, perfect 
cleanUness, a small number of lying-in beds, not by any 



NEW LYING-IN WARDS: COCHIN, PARIS. 47 

means constantly occupied, administration separate from 
that of general hospitals, and allowing the lying-in women 
to return to quarters in as few days after delivery as their 
recovery admits. 

But there is one remarkable instance in which a plan of 
construction, on the principle of the earUer British military 
female hospitals described above, has been adopted without 
having led to equally satisfactory results. 

The new ' Maternity ' belonging to the H6pital Cochin at 
Paris has been constructed on a ground-plan similar to that 
at Woolwich, viz., with two pavilions projecting in Une 
from a centre, and containing two ten-bed wards. It is in 
two floors, with small wards on the upper floor. Part of its 
sanitary arrangements are certainly not what we should 
adopt in this country, but there are many hospitals in 
which there are worse defects. 

Puerperal fever appeared in this hospital within a month 
of its being opened. 

Where so much attention had been paid to construction, 
the causes of the fever must be looked for somewhere else 
than in the ward plan. 

Dr. Le Fort has stated that puerperal fever cases had been 
retained temporarily in the wards after the development 
of the disease ; that the same nurses took charge, not only 
of cases of disease in the isolated wards, but also of women 
making healthy recoveries ; and that there is nothing to pre- 
vent the medical attendant passing almost directly from the 
autopsy of a puerperal fever case to render assistance to a 
healthy woman. 



48 NOTES ON LYING-IN INSTlTlITIONa 

This experience is very important. It shows how much 
the safety of lying-in hospitals depends on common-sense 
management, and that it would be disastrous to trust to 
improved construction alone, while everything else is left to 
take its own course. 

We now arrive at the consideration of an elementary 
point y — 



SHOULD MSDICAL STUDENTS BB ADMITTED TO 
LYING-IN HOSPITAL PRACTICE f 

This is a very grave question. Medical students were ad- 
mitted to the lying-in wards at King's College Hospital. Was 
this one cause of the occurrence of puerperal diseases there ? 

There are facts, it is true, such as those supphed by the 
Maternity and Clinique at Paris (the latter only admitting 
medical students), in both of which estabUshments the mor- 
tahty is excessive, which on first sight appear to show that 
the presence of medical students in a lying-in hospital is 
not necessarily a cause of adding to a mortality already 
excessive. But on the other hand there are facts, such as 
those given by Dr. Le Fort, admitting of a comparison being 
made between the mortality in lying-in wards to which 
medical students are admitted with the mortahty in other 
wards of the same establishment not admitting students, 
which appear to establish the point conclusively. The 
special case he cites is the following :— i 

At Vienna there are two Ijdng-in cUniques, one for 
students and one for midwives. They are both situated in 



MEDICAL STUDENTS. 



49 



tlie same hospital, and their external conditions are insuffi- 
cient in themselves to explain the facts now to be noted. 
Puerperal fever prevailed in the hospital during the same 
months in ten separate years, from 1838 to 1862, and the 
following table gives the mortality per 1,000 in each set of 
clinical wards : — 



YSABfi 


Months 


MOBT^IJTT PBB 1,000 


Ist Cliniqne 
Stndents 


2ncl Cliniqne 
Mid wives 


1838 
1839 
1840 
1842 
1844 
1844 
1845 
1840 
1847 
1856 
1862 


June 

July 

October 

December 

November 

March 

October 

May 

April 

September 

December 


9 
150 
293 
313 
170 
110 
148 
134 
179 
13 
63 


247 
34 
68 
37 
33 

7 
13 

4 

7 
105 

2 



Is it not quite clear that some bad influence was at work 
in this case on the students' side, which was not in force on 
the pupil midwives' side? That there was something else in 
operation besides epidemic influence is shown by the much 
greater frequency and severity of puerperal diseases in the 
one clinique than in the other. We may assume the fact 
without attempting to explain it, as a proof of the necessity 
of separating midwifery instruction altogether from ordinary 
hospital clinical instruction ; and does not this Vienna his- 
tory throw fresh light on the experience already alluded to 
of our midwives' school in King's College Hospital ? 

E 



50 NOTES ON LYING-IN INSTITUTIONS. 

INFLUENCE OF TIME SPENT IN A LYING-IN WARD 

ON THE DEATH-RATE. 

This very important element in the question of mortality- 
has been already referred to. There appear to be no 
extant statistics to show the relation of the death-rate to the 
period of residence. This much, however, is known — that in 
the establishments where the death rate is highest the pro- 
bable effect of length of residence appears not to be con- 
sidered, while in the cases cited where the death-rates are 
lowest the women leave the hospital as soon as they are able 
to do so. 

Dr. Le Fort, however, quotes Tamier and Lasserre of 
Paris, and Spath of Vienna, as holding that the death-rate is 
lower among women admitted some time before labour. 
'They become acclimatised' (an odd expression, when 
applied to the foul air of an establishment where there 
should be no foul air). He also says that puerperal fever is 
very rare among women brought into hospital after delivery, 
and he asks whether ' contamination does not take place 
principally and almost solely at the moment of accouchement.* 

One can only repeat, what indeed Le Fort states, that in 
these most important points of enquiry, the very elements 
are yet wanting to us. 

Some hospitals have rather plumed themselves on their 
humanity in giving shelter to poor lying-in women as long 
as possible, while in military lying-in hospitals soldiers* 
wives are obliged to go home as soon as they can, to help 
the domestic earnings. In the first class the death-rate is 
high, in the last it is low. 

The low death-rates in workhouse lying-in wards appear 



AVERAGE STAY IN LYING-IN WARDS. 51 

to support this conclusion also. These do not retain to- 
gether women not yet in labour, women in labour, women 
delivered, and convalescent women. Their principle, on the 
contrary, is to receive women when labour is imminent, and 
to send them out of the ward as speedily as possible. 

A moment's consideration will be sufficient to show how 
important a point in management this is. If there is any 
danger at all to puerperal women in a lying-in institution (a 
fact which has been proved), is it not clear that the danger 
must become cumulative? It will increase in a certain 
ratio as the length of residence increases. 

Blood-poisoning, if once begun, will not stop of itself 
unless the subject of it be removed from the cause, or the 
cause from the subject, if it stop even then. To retain both 
subject and cause together is simply to render certain that 
which under better management might have been evanes- 
cent. The more this question is considered the more im- 
portant does it appear, as involving an element exercising a 
very considerable influence on the ultimate fate of inmates 
of lying-in institutions. The institution, by retaining its 
inmates, becomes a hospital ; and, as such, subjects its 
inmates to hospital influences while in the most susceptible 
of all conditions. 

The absence of information in almost all published statistics 
on the point would be grot^isque, if it were not alarming from 
the carelessness it shows. With some difficulty the follow- 
ing few meagre data have been scraped together as to the 
average number of days lying-in women spend in the under- 
mentioned institutions : — 

s 2 



52 NOTES ON LYING-IN INSTITUTIONS. 



14 „ 



14, 18, 21 

17,18 

18,20 

16 



Soldiers' Wives' Hospitals . . . . 10 to 12 days 

Liverpool Wbrkhouse Lying-in Wards 

London Workhouse Lying-in Wards • 

Paris Maternity • • • • • 

Paris Clinique . • « • « 

King's College Hospital 

This involves the question of management, which is next to 
be considered. 

EFFECT OF GOOD MANAGEMENT ON THE SUCCESS OF 

LYING-IN ESTABLISHMENTS. 

The most important experience which can be had as to 
the effect of good management in preventing the develop- 
ment of puerperal diseases is afforded by the results of mid- 
wifery cases in workhouse infirmaries. In none of these 
institutions is there any great refinement of construction or 
of sanitary appliances, and nevertheless their death-rates 
have been much lower than those of maternity institutions 
generally. 

In Table V. are given the statistics of the lying-in wards 
of Liverpool workhouse for thirteen years. During this 
period there were an approximate number of 6,396 deliveries 
and 58 deaths, giving a total death-rate of 9*06 per 1,000. 

Of these deaths 22 were from puerperal diseases 
— equal to a death-rate of 3*4 per 1,000. There were 
14 deaths irom accidents of childbirth — equal to a death- 
rate of 2*2 per 1,000. The aggregate death-rate from 
puerperal diseases and accidents of childbirth was 5*6 per 
1,000. 

These deaths are said to include all among puerperal 
women dehvered in these lying-in wards, whether occurring 
within or without the maternity division. Mr. Barnes, the 



LIVERPOOL WORKHOUSE STATISTICS. 



5a 



medical officer of the establishment, states that he can 
* answer for this with certainty ' during the last 5 years. 
Also, that no lying-in woman is discharged out of the work- 
house unless in perfect health, so that no puerperal death can 
have happened after discharge. Mr. Barnes has farther 
been kind enough to supply data for the following 3 years' 
statistics, to show the general character of the cases which 
have furnished these low death-rates. 



Summary of Cases Delivered in the Lying-4n Wards of 

Liverpool Workhouse 1868-9-70. 



it 



}9 



tf 



}f 



Number of women attended in labour : natural . 
„ „ f, premature 

married . 
single 
Males bom 

Females bom 

Mothers who died in or from labour . 

Children bom dead .... 

Women confined at or above 40 years of age 

„ „ below 20 

Greatest age at delivery 
Youngest „ .... 

Number of first confinements . . 

Twin births 

Triplets 

Labours followed by flooding 

„ accompanied by convulsions . 

,, f, retained placenta . 

Forceps cases 

Craniotomy cases • • ^ • • 
Version cases ...... 

Presentations: head 

breech .... 

feet 

arm 



99 



• 
3 


Years 




Total 


1868. 


1869 


1870 


1,396 


511 


443 


442 


4 


1 


15* 


20 


164 


159 


142 


466 


361- 


286 


300 


936 


295- 


223 


228 


746 


216' 


226 


223 


664 


2t 


n 


2§ 


6 


79 


68 


68 


196 


8 


4 


9 


21 


105* 


98 


81 


284 


46 


42 


44 


— 


17 


16 


16 


•— 


223. 


207 


106 


536 


1 


5 


7 


13 








1 


1 


3 








8 


2 


1 


2 


5 


8 





8 


6 


7 


4 


4 


16 


1 








1 


2 





1 


8 


484 


426 


426 


1,336 


22 


12 


15 


49 


4 


10 


11 


25 


1 








1 



• Prematoxe births : Seyen monihs, 8 ; deaths, 6 : six months, 6 ; deaths, 6 ; fiye months, 1 ; 
death, 1. i 1 puerperal convulsions, 1 bowel disease. 

X 1 after instrumental labour, 1 metritis. $ 1 heart disease, 1 dropsy. 



54 



NOTES ON LTINQ-IN INSTTTUTIONa 



Subjoined ia also a Table of the deaths and causes of death 
year by year for 13 years : — 

Summary of Deaths and Gauaea of Death vn the Lyvng-vn. Warda 
of Liverpool Workhouse for Years 1858-1870. 



Morbus cordis . 
Pueumonia . 

Phthisis .... 
Debility .... 
Epileptic cocYuLdons 
Puerperal fever 
Jaundice .... 
Phlegmawa doletis . 
EsrhaustioQ 

SSr.'"" : : 

Inquest 
l^ryngitia 

Obstructed labour . 
Ti-pbus, post partum 

Sf .^' : : : 

Bupture of uterus . 
Brigbt's disease 
Invaginated bowel . 
Instrumental labour (fever) 
Metritis .... 


,8^ 


-:- 


8«, 


^2 




- 


3 

1 


ISST 

1 

1 

1 


>» 


IE«. 


1 

T 


2 

I 
1 
1 
2 


T 

T 

1 
1 


1 

■2 

1 

J 

I 

I 
1 


1 

1 

1 

T 
1 
1 
1 


6 

1 


1 
1 


2 
1 

T 

1 


2 


- 

1 
t 


1 
1 


Deatlis .... 


7 


5 





7 


7 


3 


B 


3 


4 


3 


2 


2 


3 




450 


625 


511 


443 


442 



tbettittejtaa ism-t-; 
■bow tli^ C& dcsth'nte I 

Let us now see what the arrangements are for this dasa 
of cases. The lying-ia department of Liverpool workhouse 
is situated in a wing of the female general hospital, contiguoua 



LIVERPOOL WORKHOUSE MANAGEMENT. 55 

to the surgical wards. The wing has windows along the 
two opposite sides and at one end ; but the space is so 
divided oflf by partitions as to form five wards, each of which 
has windows along one side only. The wards are allotted 
in the following manner : — 

Two of them, opening into each other, and facing the same 
way, contain each twelve double beds, affording accommo- 
dation for 24 inmates per ward, 48 in all, at 345 cubic feet 
per inmate. These two wards are devoted to the reception 
of pregnant women before deUvery. The opposite half of 
the wing is divided into two wards, corresponding to the 
two pregnant wards ; one of these is the delivery ward, and 
contains seven beds, at nearly 1,200 cubic feet per bed. 

Entering from this deUvery ward is the lying-in ward, 
lighted by windows at the end. This ward contains 14 
beds, at 900 cubic feet per bed. The other ward, entering 
from the delivery ward in the same Une, is for convalescents, 
and contains eleven beds, at 762 cubic feet per bed. The 
W. C.'s, &c., are between the wards in the wing, in a very 
objectionable position. 

For these and the following details I am indebted to the 
kindness of Mr. Barnes, who also supplied me with the 
statistics abstracted on Table V. 

The following is the routine management of this estab- 
lishment : — 

All the wards are Ume-washed three or four times a year. 
They are shut up and fumigated after the occurrence of any 
serious case of illness. The floors are washed daily. 

The beds in the pregnant, lying-in, and convalescent wards, 



56 NOTES ON LYING-IN INSTITUTIONS. 

are generally all or most of them occupied ; but the number of 
occupied beds in the deUvery ward rarely exceeds four or 
five. 

The bed clothes are changed after each delivery, and the 
beds, which are of straw, after every third delivery. 

The patients consist for the most part of unmarried women.^ 
They are admitted into the pregnant wards, where they 
remain for a varying interval of from days to months, from 
whence they are removed to the delivery ward ; about a fifth 
part of the women are admitted directly from the town to 
the delivery ward. 

They remain on an average eight hours in the delivery 
room, whence they are removed to the lying-in ward, where 
they remain five or six days. They are then admitted to the 
convalescent ward, and are finally discharged fourteen days 
after labour, one half to the town, the other half into other 
parts of the workhouse. 

An important part of the management is that the inmates 
of the pregnant wards only inhabit those wards at night, 
being engaged during the day in various occupations within 
the workhouse, but not about the lying-in women, as in the 
Paris Maternity. 

Cases are not taken into the lying-in division unless labour 
has begun, or is supposed to be imminent. 

Any case of illness occurring in the lying-in department is 

^ An attempt has been made in certain cases to account for the high death- 
rates of lying-in hospitals from the large proportion of unmarried women 
admitted. This opinion is directly contradicted by the experience of Liverpool 
workhouse, where out of 1,401 deliveries of women, 936 of whom, or two-thirds^ 
were unmarried, there were only 6 deaths » 4*2 per 1,000 death-rate. 



LIVERPOOL WORKHOUSE MANAGEMENT. 57 

at once removed to the ' class sick nursery,' to the lock or 
other division. 

The nurses engaged in the lying-in division attend also 
cases in the ' class sick nursery/ and are periodically changed. 
Any case which they cannot manage is referred to the resi- 
dent medical officer on duty. 

There are three of these officers, who relieve each other 
every eight hours day and night. The officer on duty is liable 
to be called on to visit any part of the workhouse or hospital 
during his turn of duty, so that it might happen occasionally 
that the medical officer might be called from the hospital to 
the lying-in division. 

If feverish symptoms show themselves in any patient in 
the lying-in division, the practice is to isolate the case or 
to transfer it to some other division of the workhouse. The 
ward is then closed, fumigated, cleansed, and hme-washed, 
before being again used. 

This proceeding has only been necessary twice within the 
last four years. 

Until recently, the whole of the deUveries, which amounted 
to an average of about 500 a year, were under the charge of 
one paid officer and a pauper who, without any payment 
or extra diet, delivered nearly every case and worked both 
night and day. 

There are several points in this procedure which are of 
great importance, as bearing on the general question of suc- 
cessful management of lying-in establishments : — 

1. The building, although situated in a large commercial 
town, is on a high, isolated, and freely ventilated locaUty. 



58 NOTES^ ON LYING-IN mSTITUTIONS. 

2. It is not connected with a general hospital or medical 
school, or with any of their risks. 

3. There is a constant change of wards : — pregnant ward, 
dehvery ward, lying-in ward, recovery ward, body of the 
house. There is, in short, as little risk as possible of the 
cumulative blood-poisoning process already referred to. 

4. Frequent cleansing and lime- washing. 

6. Passing women who have been deUvered as speedily 
as possible out of the division altogether, either into the 
house or outside. 

6. The deliveries being conducted by a woman specially 
attached to the delivery ward, and no part of whose duty it 
is to attend sick. 

7. The immediate isolation or removal of all cases ex- 
hibiting feverish symptoms and their treatment out of the 
division. 

8. The reduction of intercommunication between the 
lying-in and hospital divisions to the smallest possible 
degree on the part of medical oflScers and nurses. 

The practical result of this system of management has 
been, as we have seen, that the lying-in division of this work- 
house, although working under many singular disadvantages, 
has escaped the usual fatality of special lying-in hospitals. 

During the thirteen years included in the tables there has 
been no epidemic, and the deaths have almost always been 
single and disconnected. 

The experience of lying-in wards in London workhouses 
somewhat resembles the experience of Liverpool workhouse. 

In the report of the committee appointed to consider the 



LONDON WORKHOUSE MANAGEMENT. 59 

cubic space of metropolitan workhouses, 1867, is given a 
table. No. 11, shewing the number of deliveries and deaths 
after deUvery during five years in forty metropohtan 
workhouses. 

The leading facts are abstracted in Table VI. Work- 
houses in which deaths after delivery took place, during the 
five years, are separated in the abstract from workhouses 
in which no deaths took place. 

There were during these five years in all the workhouses 
11,870 deliveries and 93 deaths, giving a death-rate of 
7*8 per 1,000. The deaths from puerperal diseases 
amounted to 39, giving a death-rate of 3*3 per 1,000. 
There were 20 deaths from accidents of childbirth; being a 
death-rate of 1*7 per 1,000. The total death-rate due to 
both classes was 5 per 1,000. 

The largest number of deliveries took place in Maryle- 
bone and in St. Pancras. In the former, on an average of 
243 deUveries per annum, the death-rate was 8*2 per 1,000. 
One half of this, however, was due to consumption. Of 
the remaining deaths 3 were due to puerperal diseases 
(2*4 per 1,000) and 2 to accidents. The death-rate due 
to puerperal diseases and accidents of childbirth was thus 
4-1 per 1,000. 

In St. Pancras workhouse, on an average of 200 deliveries 
per annum, the death-rate was 11 per 1,000, of which 
9 per 1,000 were due to puerperal diseases. Kecent 
disclosures with regard to St. Pancras workhouse may to 
some extent account for this high death-rate. The number 
of deliveries in these two workhouses bring them almost 
within the category of lying-in hospitals. 



60 NOTES ON LYING IN INSTITUTIONS, 

There are foiir other workhouses in which the annual 
deUveries are respectively 171, 120, and two of them 111, 
while in all the others the numbers fall much below 100. 

In one such instance (Holborn), where the deUveries have 
averaged fifty a year, the death-rate was exceptionally 
high, 24 per 1,000, one half of which was due to 
puerperal disease. In another instance, St. Mary's, Ishngton, 
with seventy-five dehveries per annum, the death-rate 
averaged 29 per 1,000. But the causes are not stated, 
and cannot now be ascertained. In Whitechapel, where 
there were 111 deliveries per annum, the death-rate was 
10*8 per 1,000, one half being due to puerperal 
diseases. 

It is possible that local enquiry might elucidate the 
causes of this mortality. The cases are, however, exceptional 
to the experience of London workhouses, viz. that the 
death-rates from puerperal diseases and accidents of child- 
birth are scarcely higher than they are in all England, town 
and country. Let us try to ascertain how far the management 
adopted may have led to these comparatively favourable 
results. 

The conditions for recovery in a great majority of the 
London workhouse lying-in wards are at least as favourable as 
they are in the Liverpool workhouse; in most cases un- 
doubtedly more so, as will immediately be seen when we 
consider that the average annual number of deUveries in 
Liverpool workhouse is more than twice that of the two 
largest London workhouses, and from five to ten times 
most of the others ; that in the London workhouses the rule 



LONDON WOKKHOUSE MANAGEMENT. 61 

is to have many unoccupied beds, while this is the exception 
in the Liverpool workhouse. 

The cardinal principle in the managenient of these 
London workhouse lying-in wards appears to be this : their 
occupants are a fluctuating number ; often the wards have 
but one woman at a time, and the cubic space for each of 
these women is ' in fact the cubic space of the whole ward.' ^ 
Sometimes, but only for brief periods, all the lying-in beds 
may be occupied. For much longer intervals the occu- 
pants are very few in number, so that each has a large 
proportion of cubic space, and sometimes the wards in some of 
the workhouses are empty. There are no medical schools 
attached to the institutions, and no medical students who 
may have passed from a case of erysipelas or from the post- 
mortem theatre to the lying-in bedside ; there is the 
possibility of removing immediately any case of febrile or 
other disease which may occur in the lying-in ward into 
the general sick wards of the workhouse ; there is discharge 
of convalescent cases at the earliest possible period, either to 
their own homes or to other parts of the est>ablishment ; 
these conditions, together with the paucity of numbers 
and the occasional vacating and rest of the wards, appear 
to constitute the main difference between a workhouse 
lying-in ward and a lying-in hospital. 

Li both classes of establishments the same attention is 
doubtless bestowed on ventilation, cleanliness, and frequent 
change of bedding. 

* In Lambeth and St. Pancras the wards are generaUy full. 



62 NOTES ON LYING-IN INSTITUTIONS. 



MANAGEMENT OF MILITARY LYING-IN WARDS. 

The lying-in arrangements provided for soldiers' wives 
are as follows : — 

The rule is that women shall be delivered in quarters, 
provided there be decent accommodation. At a number of 
the larger stations, where suitable married quarters have not 
yet been fiilly provided, there are female hospitals, attached 
to which, as we have already seen, is a delivery and lying-in 
ward, with the usual offices. In the specially constructed 
hospitals the wards are of a good size, well-lighted, warmed 
and ventilated. If all the beds were occupied, the space 
would be 1,300 cubic feet per patient. But this is an event 
which rarely or never happens, so that there is always 
plenty of room and good ventilation. 

If ^ a woman requires admission, her husband applies to 
the medical authorities for a ticket. No woman with a 
disease considered • to be infectious is admitted. The 
women usually follow their ordinary avocations until obliged 
to proceed to hospital by imminent labour. They are 
taken there in cabs, all the necessary arrangements for the 
lying-in having been made, if possible, by previous inti- 
mation. The woman is delivered in the deUvery ward, and 
is thence transferred to the lying-in ward. As a rule, the 
lying-in pavilion in these female hospitals is distinct in 
all its arrangements for nursing from the pavilion for 
general cases. Infectious cases are not received into the 
same hospital, except at Aldershot. 

^ Thepe nrrangements are commonly the same in civil lying-in institutions. 




MILITARY LYING-IN MANAGEMENT. G3 

In these hospitals for soldiers' wives the time which 
elapses from the admission to the discharge of the women is 
usually ten, and in some cases twelve days. 

At Aldershot four * Sisters ' are now at work in the 
soldiers' wives' hospital. One was trained as midwife, and 
took charge of the midwifery cases early in 1867. The 
Sister midwife has sole charge of the lying-in women for 
five or six days. They are then passed into a third ward, 
and are nursed by the Sisters who attend the ordinary cases 
(which are, however, of course in a separate ward). 

The Sisters do not help the midwife, as a rule. Only the 
Superior, on an emergency, and one for scrubbing floors 
periodically, enter the midwifery wards (i.e. the delivery 
and lying-in wards). 

In 1869 Aldershot had no fatal case among the lying-in 
women. 

[ The * infection wards ' are nursed by ordinary nurses, 
and in cases of children by the parents.] 

It will be seen, therefore, that at Aldershot the midwife 
has nothing to do with the general cases, and the matron 
is not now the midwife. Both there and at Woolwich the 
lying-in nursing is quite separate from the general nursing. 

The medical officer remarks, as to the two deaths in 
1869 at Woolwich : * Two cases of puerperal peritonitis 
after bad labours, requiring instrumental and other assistance, 
died, but the disease did not extend. My opinion is that 
the coldness of the wards, though objectionable, has a great 
deal to do with the comparative immunity hitherto enjoyed 
as regards the germination and extension of contagious 
diseases.' 



64 NOTES ON LYING-IN INSTITUTIONS- 

It need scarcely be said that these new hospitals are 
models of cleanliness. 

In the Colchester Hut the patient is received into a sepa- 
rate compartment, of which there are four, where she is 
delivered and remains until discharged to quarters. 

It is very rarely indeed, if ever, that all the four compart- 
ments are occupied simultaneously. The average stay is ten 
days ; the average number of deliveries a year under 50. 

This hut does not form part of a hospital. It is a separate 
estabhshment, solely for lying-in women, as such accommo- 
dation should always be. 

Note. — There is another reason, though it may be termed a 
fanciful one, for altogether disconnecting lying-in institutions 
with general hospitals, and even with the name and idea of 
hospital. It is this : there must be a certain death-rate 
in a general hospital, receiving as it does fatal diseases and 
fatal accidents, as long as men and women* have fatal dis- 
eases and fatal accidents. 

But lying-in is not a fatal disease, nor a disease at all. It 
is not a fatal accident, nor an accident at all. 

Unless from causes unconnected with the puerperal state, 
no woman ought to die in her lying-in ; and there ought, in a 
lying-in institution, to be no death-rate at all. 

It is dangerously deadening our senses to this fact — ^viz., 
that there ought to be no deaths in a lying-in institution — if 
we connect it in the least degree with the name of hospital, 
so long as a hospital means a place for the reception of 
diseases and accidents. 

In French statistics, this confusion of ideas, were it not 



RECAPITULATION. 65 

ghastly, would be ludicrous. * Admissions/ under the head 
* Malades,' include not only the lying-in women, but the 
new-bom infants, which appear to be ' admitted ' to life and 
to hospital together, as if life were synonymous with disease, 
so that, e.g. 4,000 * Admissions,' in such a year, to the 
Paris Maternity would mean 2,000 deUveries, 2,000 births — 
[and — ^how many deaths ?] 



RECAFITULA TION. 

In summing up the evidence regarding excessive mortality 
in lying-in institutions and its causes, it appears— 

1. That, making every allowance for unavoidable inaccu- 
racies in statistics of midwifery practice, there is sufficient 
evidence to show that in lying-in wards there reigns a 
death-rate many times the amount of that which takes place 
in home dehveries. 

2. That a great catlse of mortality in these establishments 
is 'blood-poisoning,' and that this fiiris^s horn the greater 
susceptibility of lying-in women to diseases doiiiiected wit!) 
this cause. From whence it follows that in many lying-in 
wards, as at present arranged and managed, there must be 
conditions and circumstances apart from those belonging to 
the inmates personally, which aid in the development of this 
morbid state. 

3. That the risks to which lying-iii Women afd exposed 
from puerperal diseases are increased by crowding cases in 
all stages into the same room or under the same roof; by 
retaining them for too long a period in the same room ; 



66 NOTES ON LYING-IN INSTITUTIONS. 

by using the same room for too long a period without 
cleansing, evacuation, rest, and thorough airing: but that 
the death-rate is not always in proportion to the number of 
lying-in cases which have passed through the hospital. 

It follows from this that, other things being equal, a high 
death-rate may take place in a small hospital constantly used 
up to its capacity as well as in a large hospital constantly 
used up to its capacity. 

4. That there are superadded causes in some establish- 
ments which add greatly to their dangers. Among these 
may be reckoned the following : — 

(a) Prevalence of puerperal fever as an epidemic outside 

the hospital. 
(6) Including midwifery wards within general hospitals, 
thereby incurring the risk of contaminating the air 
in midwifery wards with hospital emanations. 

(c) Proximity to midwifery wards of post-mortem theatres 

or other external sources of putrescence. 

(d) Admitting medical students from general hospitals or 

from anatomical schools to practice or even to visit 
in midwifery wards without special precautions for 
avoiding injury. 

(e) Treating cases of puerperal disease in the same ward, 

or under the same roof, with midwifery cases. 

(/) Permitting the same attendants to act in infirmary 
wards and in lying-in wards, and using the same 
bedding, clothing, utensils, &c., in both. 

(g) Most probably also — especially in certain foreign hos- 
pitals — want of scrupulous attention to ventilation. 



RECAPITULATION. 67 

and to cleanliness in wards, bedding, clothing, 
utensils, and patients, and in the clothing and 
personal habits of attendants. 

In short, the entire result of this enquiry may be summed 
up, in a very few words, as follows : — ^A woman in ordinary 
health, and subject to the ordinary social conditions of her 
station, will not, if delivered at home, be exposed to any 
special disadvantages likely to diminish materially her 
chance of recovery. But this same woman, if received into 
an ordinary lying-in ward, together with others in the 
puerperal state, will from that very fact become subject to 
risks not necessarily incident to this state. These risks in 
lying-in institutions may no doubt be materially diminished 
by providing proper hospital accommodation, and by care, 
common sense, and good management. And hence the real 
practical question is, whether it is possible to ensure at all 
times the observance of these conditions. 

The great mortahty in lying-in hospitals everywhere is 
no doubt a strong argument against such a result being 
attainable ; so much so that, in the absence of this security, 
the evidence in the preceding pages appears sufficient to 
warrant the question being raised, whether lying-in hospitals, 
arranged and managed as they are at present, should not be 
forthwith closed ? 

Can any supposed advantages to individual cases of des- 
titution counterbalance the enormous destruction of human 
life shown by the statistics ? 

Without vouching for the entire accuracy of Le Fort's 
data, they may still be taken generally as showing ap- 

V 2 



68 



NOTES ON LYING-IN INSTITUTIONS. 



proximately the penalty which is being paid for the supposed 
advantages of these institutions. It is this : (see Table XV.) 
for every two women who would die if delivered at home, 
fifteen must die if delivered in lying-in hospitals. Any 
reasonable deduction from this death-rate for supposed 
inaccuracy will not materially influence the result. 

Table XV., abstracted from Tablbs III. and X., showing Com- 
parative Mortality among Lyvag-in Women m Hospitals and 
at Home. 



Total for aH hospitals 
Total delivered at borne . 

Excess of deaths per thousand delivered 
in hospitals .... 


DeUveries 


Deaths 


Deatluper 
Thousand 


888,312 
934,781 


30,394 
4,405 


34 

4-7 






29-3 



The evidence is entirely in favour of home delivery, and 
of makmg better provision in future for this arrangement 
among the destitute poor. 



CAN TMJS ARRANGEMENT AND MANAGEMENT OF 
LYING-IN INSTITUTIONS BE IMPROVED? 

Must we, then, surrender the principle of lying-in institu- 
tions altogether, and limit the teaching of midwifery nurses 
solely to bedside cases at home, notwithstanding the well- 
known difficulties of teaching pupils at the beginning of 
their course elsewhere than in an institution ? We will try 
to reply to this question ; and, in doing so, perhaps some 



CAN ARRANGEMENTS BE IMPROVED? 69 

light may be thrown on another question, viz. : how to im- 
prove existing lying-in establishments so as to reduce the 
mortality in them. 

Evidence suflScient ha& been collected to show that no one 
panacea will enable us either to possess a perfectly healthy 
building, or to improve existing hospitals. 

Much has been written about the saving effect of small 
hospitals ; but it is certain, from what has been already said, 
that the small-hospital idea is not sufficient of itself. It is, 
however, a very important idea, because all hospital prob- 
lems are simplified by subdivision of the buildings. So far 
as we know, every one who has carefully studied the subject 
has given a preference to small lying-in establishments over 
large ones ; but we should certainly be disappointed if we 
trusted to smallness of size alone for reducing the mor- 
tality. 

The evidence further shows that in any new plan in- 
firmary wards must be kept quite detached from lying-in 
wards. They should be in another part of the ground, and 
should be provided with their own furniture, bedding, 
utensils, stores, kitchen, and attendants. 

The same arrangement, at least in principle, should be 
carried out at all existing lying-in establishments, and every 
case of disease should at once be removed from the lying-in 
wards to the infirmary, and be separately attended there. 

In our proposed midwifery school the whole attendance 
would be supphed by midwives and pupil midwives, with a 
physician accoucheur, to make his visit twice a day, to be 
sent for in time of need, and to give instruction to the pupil 



70 NOTES ON LYING-IN INSTITUTIONS. 

midwives by lectures and otherwise ; and in this way we 
should escape the dangers of introducing medical students. 

Applying the same principle to lying-in wards to which 
medical students are admitted, there can be no doubt that a 
responsibility of the very gravest kind attaches to all 
teachers and managers of lying-in hospitals who do not 
satisfy themselves that students admitted as pupils have 
nothing to do, either with general hospital practice, or with 
anatomical schools, during the period. Midwifery instruction 
should be treated as a matter quite apart. 

What has been already said need scarcely be repeated^ 
about the dangers of connecting midwifery wards with 
general hospitals. The simple facts are sufficient to show 
that all midwifery wards of this class should be at once 
closed. 

As a general result of this enquiry, apphcable to all lying- 
in wards, the evidence shows that very much indeed of the 
success depends on good and intelligent administration and 
management. 

Suppose that all these precautions could be carried out, 
will the cost and difficulty of giving effect to them neces- 
sarily lead to the aboHtion of all accommodation for mid- 
wifery cases, or for teaching midwifery ? 

We reply. No. The facts already adduced clearly show 
what may be done in this matter. 

They prove, in the first place, that lying-in women should, 
as a rule, be dehvered at home. And, as a consequence, 
that whatever provision may be made for cases of special 
destitution, or for midwifery teaching, such provision should 



CAN MANAGEMENT BE IMPROVED? 71 

be assimilated as far as practicable to the conditions which 
surround lying-in women in fairly comfortable homes. 

These conditions are realised, and in some instances no 
doubt improved on, in the better class of workhouse lying- 
in wards, and of lying-in huts for soldiers' wives. 

The favourable results arrived at in many of these insti- 
tutions appear to show that a little more care would lower 
the death-rate still further. 

In every instance where it is considered necessary to 
organise lying-in accommodation by voluntary effort, the 
same principles should be kept in view. 

The success which has attended Waterford Lying-in Hos- 
pital, abeady mentioned, shows how much may be done in 
rendering such accommodation a real boon to the poor. 

A single hut, like the Colchester Hut, erected in a needy 
locality, would supply, and that safely, all the accommo- 
dation wanted. But for a training school of midwives and 
midwifery nurses other accommodation is required, and of 
a far more costly character. 

It is true that any sort of building may be leased or 
bought and altered, or added to, and told off as a training 
school ; but after what has been said, to take such a course 
would be to ensure killing a certain number of mothers for 
the sake of training a certain munber of midwives. If we 
are to have a training school at all, we must, before all 
things, make it as safe for lying-in women to enter it as to 
be delivered at home ; and having made up our minds what 
is necessary for this purpose, we must pay for it. 



72 NOTES ON LYING-IN INSTITUTIONS. 



CHAPTER n. 

CONSTRUCTION AND MANAGEMENT OF A LYING-IN IN- 
STITUTION AND TRAINING SCHOOL FOR MIDWIFES 
AND MIDWIFERY NURSES. 

To APPLY all this experience to the construction and 
organisation of a school for midwives and midwifery 
nurses ^ is the next thing : — 

Everybody must be bom, and every woman, at least in 
this kingdom, is attended at the birth of her child by some- 
body, skilful or unskilful. Except in the case of multiple 
births, there are therefore as many attendances as there 
are births in the Eetums of the Eegistrars-General. 

This it is which makes the subject of midwifery nursing 
of such paramount importance. 

Lying-in is an operation which occurs in England to seven 

^ I call a midwife a woman who has received such a training, scientific and 
practical; as that she can undertake all cases of parturition, normal and abnormal, 
subject only to consultations, like any other accoucheur. Such a training could 
not be given in less than two years. 

I call a midwifery nurse a woman who has received such a training as wiU 
enable her to undertake all normal cases of parturition, and to know when the 
case is of that abnormal character that she must call in an accoucheur. 

No training of six months could enable a woman to be more than a midwifery 
nurse. 



CAN STATISTICS BE IMPROVED? 73 

women out of a hundred annually. In 1868 there were 
786,858 children born alive in this country, wherefore for the 
midwives and midwifery nurses to be trained there will 
always be occupation and custom enough ; whereas the 
occupation and custom for a surgical operator is, it is to be 
hoped, comparatively small, except in Franco-German wars. 
Even there we may trust that 7 out of 100 had not to 
undergo an operation. Certainly to 7 out of every 100 
annually a surgical operation in England does not occur. 

Between midwifery nursing and all other hospital 
nursing there is this distinction, viz. : the operator is her- 
self the nurse ; and the head-operator (or midwife) ought to 
be a woman, and is, in Paris and Vienna, and elsewhere. 

Lying-in patients are to be compared to surgical (or 
operation) patients, not to medical patients, and should be 
perfectly well in health. 

Since lying-in is not an illness, and lying-in cases are not 
sick cases, it would be well, as already said, to get rid of 
the word ' hospital ' altogether, and never use the word in 
juxtaposition with lying-in women, as lying-in women should 
never be in juxtaposition with any infirmary cases. 

As to amount of work, necessary administrative con- 
veniences and the hke, a lying-in institution is to be com- 
pared to a surgical, not medical hospital, or rather to a 
hospital for operations. 

It has been already shown that great improvements are 
required in the manner of keeping midwifery statistics, and 
that many data are wanting for this purpose. It would be 
altogether wrong to deal with these statistics on the same 



74 NOTES ON LYING-IN INSTITUTIONS 

principles as if they were general hospital statistics. Lying- 
in is neither a disease nor an accident, and any fatality 
attending it is not to be counted as so much per cent, of inevit- 
able loss. On the contrary, a death in childbed is almost a 
subject for an inquest. It is nothing short of a calamity 
which it is right that we should know all about, to avoid it 
in future. A form of record is appended (Table XVI.), 
which appears to afford the means of registering the re- 
quired information. 



I. CONSTRUCTION OF A LYING-IN INSTITUTION 

What then, first, should be the principles of construction 
for a lying-in institution, in order to combine safety for the 
lying-in women with opportunity of training for the pupil 
midwives ? And, 

1. How many Beds to a Ward? 

Not more than four. 

Or single-bed wards might be arranged in groups of 
four. 

Also, it must always be borne in mind that four beds 
mean eight patients. There are two patients to each bed 
(unless it is meant to kill the infants) to use up the air, 
which is besides used up by a necessarily far larger number 
of attendants than in any general hospital. For, during the 
time the mother is incapable of attending to the infant, the 
infant is incapable of attending to itself. Also, an exhausted 



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76 NOTES ON LYING-IN INSTITUTIONS. 

mother, and feeble, almost lifeless infant, cannot ring a bell 
or make themselves heard. Indeed, an infant which cannot 
cry is in the greatest danger. 

For all this provision must be made. There are scarcely 
two points in common between a lying-in institution and a 
general hospital. 

2. How many Wards to a Floor f 

Only one four-bed ward, or four one-bed wards in a 
group. 

3. How many Floors to a Pavilion {hut or cottage) f 

Two, at most. In every alternate pavilion better only one 
floor, unless the pavilions be so far apart as to cover an 
extent of ground which would make administration almost 
impossible, and cost fabulous. 

How many Beds to a Pavilion or Hut f 

There would therefore be no more than eight beds, and 
in each alternate pavihon no more than four beds. 

How many Pavilions or Huts to a Lying-in Institution ? 

Not more than four two-floored pavilions, two one-floored 
pavilions, and two two-floored delivery pavilions ; unless, 
indeed, building space can be given, with aU its cost and 
administrative difficulties. 



HOW MUCH SPACE TO THE BED? 77 

4. How much space to the Bed ? 

The minimum of ward cubic space for a lying-in woman, 
even where the delivery ward is, as it ought always to be, 
separate, is 2,300 cubic feet in a single-bed ward, and 1,900 
cubic feet in a four-bed ward. 

[In ordinary army wooden huts, where the air comes in 
at every seam, this space may be less.] 

As it is a principle that superficial area signifies more 
than cubic space, the surface of floor for each bed should 
not be less than 150 square feet per bed in a four-bed ward, 
and in a single-bed ward not less than 190 square feet, 
because this is the total available space for all purposes in 
a single-bed ward. This space has to be occupied, not 
only by the lying-in woman and her infant, and perhaps 
a pupil midwife washing and dressing it at the fire, but 
often by the midwife, an assistant, possibly the medical 
officer, and pupil midwives. In a four-bed ward there is 
space common to all the beds. 

The delivery Ward 

Ought to be separate in every lying-in institution ; must be 
separate in an institution of more than four or five beds, 
though in separate compartments. 

Every delivery bed should have a superficial area of not 
less than 200 square feet, and a cubic space of not less than 
2,400 cubic feet* 



78 NOTES ON LYING-IN INSTITUTIONS. 

5. How many Windows to a Bed f 

One at least to each bed. Two beds and two windows 
on each side of the four-bed ward. 

In a single-bed ward the bed should not be placed 
directly between window and door. And it must never be 
in an angle. There must be room for attendants on both 
sides the bed. 

This is still more essential in a delivery ward. Each bed 
should be lighted on both sides by windows, and should have 
at least five feet of passage room on either side. 

6. What are healthy Walls and Ceilings and Floors f 

Oak floors, polished ; furniture also ; impervious glazed 
walls and ceilings, or frequent lime-washing. 

All that has been so justly said as to the necessiiy of im- 
pervious polished floors and walls for hospitals applies ten- 
fold to lying-in institutions, where the decomposition of dead 
organic matter, and the re-composition of new organic 
matter, must be constantly going on. 

It is this, in fact, which makes lying-in institutions so 
dangerous to the inmates. 

And it may literally be said that the danger increases 
as the square of the number of in-cases. 

Lying-in ' infection ' is a very good illustration of what 
' infection ' really means, since parturition is not infectious or 
' contagious.' 

The excessive susceptibihty of lying-in women to poison- 
ous emanations, the excessively poisonous emanations from 



HEALTHY WALLS AND FLOORS. 79 

lying-in women — these constitute a hospital influence on 
lying-in cases brought together in institutions, second to no 
influence we know of exercised by the most ' infectious ' or 
' contagious ' disease. 

The death-rate is not much higher among women lying- 
in at home in large towns than in healthy districts. There- 
fore the agglomeration of cases together and want of 
management required to meet it must bear the blame* 

As to floors, the well-laid polished floor is a sine qvA non 
in a lying-in institution, where, with every care, slops, 
blood, and the like, must frequently be spilt on the floor. 

7, What is a healthy and well-lighted Delivery Ward ? 

There must be two separate deUvery wards for each 
floor of the whole lying-in institution, so arranged and 
connected under cover that the lying-in women may be 
removed after delivery to their own ward. And for this 
purpose the corridors must admit of being warmed during 
winter, especially at night, so as to be of a tolerably equable 
temperature. 

Unlimited hot and cold water laid on, day and night, 
W.C. sink, bath-sink, clean Hnen, must be close at hand. 

In a pavilion hospital one single-bed ward should be 
attached to each delivery ward, for an exhausted case after 
delivery, till she is able to be moved to her own ward. 

The delivery ward should be so lighted and arranged 
that it can be divided, by curtains only, into three if not 
four compartments. 



80 NOTES ON LYING-IN INSTITUTIONS. 

No woman being delivered should see another delivery 
going on at the same time. 

The delivery bedsteads stand in their compartments. 

Each delivery bed should have window light on either 
side, and also ample passage room all round and on both 
sides the bed. 

Care should be taken that no bed should stand exactly 
between door and window, on account of draughts. 

The curtains, of washing material, are only just high 
enough to exclude sight, not high enough to exclude light 
or air, and are made so as to pull entirely back when not 
wanted. Each area enclosed by the curtains should of 
course be sufficiently ample for pupils, attendants, and 
patient ; also for a low truck on broad wheels covered 
with india-rubber, to be brought in, on which the bedstead 
with the clean warm bedclothes is placed, and the newly 
delivered woman conveyed to her own ward. 

[A woman very much exhausted would be carried in the 
delivery bed to the bye-ward attached to each delivery 
ward.] 

The reason why there must be two delivery wards for 
each floor of a lying-in institution, to be used alternately, 
one ' off,' one ' on,' is that one delivery ward on each floor 
must be always vacant for thorough cleansing, lime-washing 
and rest for a given period, say month and month about. 

It is understood that newly-dehvered women cannot be 
removed from one floor to another. And it is quite 
necessary to have the means of keeping a corridor, along 
which a newly-deUvered woman is to be moved, at a proper 
temperature. 



DELIVERY WARDS. 81 

The position of the dehvery wards should be as nearly as 
possible equidistant from the lying-in wards, and should be 
such that the women in labour, on their way to the delivery 
ward, need not to pass the doors of other wards. 

A separate scullery to each delivery ward is indispensable ; 
such scullery to be on at least an equal scale to that of 
ward sculleries. Hot and cold water to be constantly at 
hand, night and day. A sink-bath is desirable for imme- 
diately putting in water soiled linen from the beds and the 
like. 

The scullery should contain a linen-press, small range 
with oven, hot closet at side of the fire-place, sink with hot 
and cold water, &c. A small compartment should contain a 
slop sink for emptying and cleansing bed-pans, and a sink 
about six inches deep and sunk below the floor, which is 
intended for filling and emptying a portable bath, and 
which when not required for this might be used for 
soaking linen, &c. 

Beyond the scullery, so as to be as far removed as may 
be from the traffic of the main corridor and the noises of 
the delivery ward, should be the bye- ward, with not less 
than 2,100 cubic feet of contents. 

8. Scullery^ Lavatory^ W.C. 

The necessary consumption of hot and cold water is at 
least double or triple that of any general hospital. Sinks 
and W.C. sinks must be everywhere conveniently situated. 

There must be a scullery to each four beds ; the scullery 

G 



82 NOTES ON LYING-IN INSTITUTIONS. 

must needs be much larger and more convenient than in a 
general hospital. There is often more work to be done by 
night than by day in a lying-in institution. 

All the ward appurtenances, scuUery, lavatory, &c., must 
stand empty for thorough cleansing, when the ward to 
which they belong stands empty in rotation for this purpose, 
and must not be used for any other ward. For each four- 
bed ward, or group of four one-bed wards, or for each floor 
of each pavilion, there must therefore be one scullery, with 
a plentiful unfaihng supply of hot and cold water, with sinks 
and every convenience. The reason for this is two-fold : — 

(1) To allow each scullery, with the other ward offices, to 
be thoroughly cleansed and whitewashed with its own 
group of four beds. 

(2) The work in a scullery and in all the other ward 
appurtenances day and night, night and day, is many-fold 
that which it is in a general hospital scullery. 

Besides this, general hospital patients ought never to be 
allowed to enter the scullery. 

In a lying-in scullery the infants, most exacting of all 
patients, must frequently be in the scullery. 

Even under the very best circumstances there are 
many lying-in cases among weakly women where the 
mother's state is such as to render it necessary for a ' cry- 
ing ' infant to be washed and dressed elsewhere than in its 
mother's ward. These infants a;re best washed, in that case, 
in the scullery, which must be so arranged that infants 
can be washed and dressed without being exposed to a 
thorough draught, and that nurses and babies may not be 
hustling one another. 



WARD OFFICES. 83 

There must be a good press in each scullery. A supply 
of dean Unen and other necessaries will have to be kept 
in each press in each scullery. 

The slop-sink and other appurtenances must be arranged 
so as to make allowance for the fact that the going back- 
wards and forwards for water, hot and cold, or to empty 
slops in a lying-in institution — ^where half the patients can do 
nothing for themselves, and the other half (the mothers) are 
supposed to be ready for discharge when they can go to 
the ward offices for themselves — is more than it is in general 
hospitals. 

Fixed baths are not necessary. But there must be means 
for filling with hot water moveable infants' baths at all 
hours at a moment's notice, since an infant's life often 
depends on immediate facility of hot-water bathing. 

And this besides the daily regular night and morning 
washing of infants. 

There must be also a moveable bath for each ward for 
the lying-in women, with the means for supplying it with 
hot and cold water and for emptying it. Lying-in patients 
are not able to use either fixed baths or lavatory. 

Glazed earthenware sinks should alone be used, as being 
by far the safest and cleanest. 

9. How to Ventilate Lying-in Wards, 

The best ventilation is from opposite windows. Each 
window should be in three parts, the third or uppermost to 
consist of a flap hung on hinges to open inwards and throw 
the air fi:om without upwards. 

G 2 



84 NOTES ON LYING-IN INSTITUTIONS. 

Inlet valves, to admit fresh air, and outlet shafts, to emit 
foul air, must be added to complete the natural ventilation. 

10. Furniture^ Bedding^ Linen, 

As little ward furniture as possible. As much clean linen 
as possible. 

A very large and convenient clean linen-store, light and 
dry, must be assigned to the matron : very much larger than 
would be required for a general hospital ; but no general 
hospital in London supplies a good standard for such. 

There must be in each scullery, besides, a clean linen-press. 

There should be a very ample and convenient place for 
bedding. 

Mattresses, blankets and the like, have to be renewed, 
taken to pieces and washed — especially those used in the 
delivery ward — many times oftener than in any general 
hospital 

The rack for linen should be along the middle of the linen- 
store. 

There should be space for a bedding-rack along one end, 
taking about three feet six inches from the length of 
the room for linen. Space for some spare mattresses and 
bolsters will be necessary ; and they should be stowed near 
to a lift. 

A linen-store requires thorough lighting, ventilating, and 
warming. Three windows are better than one. The hnen 
must of course be kept dry and aired. 



WATER SUPPLY. 85 

11. Water Supply, Drainage, Washing, 

Unlimited hot and cold water supply, day and night, 
should be laid on all over the buildings. 

All drains and sewers must be kept outside the walls of 
the buildings, and great care should be bestowed on trapping 
and ventilating them, to prevent foul air passing into the 
institution. 

The washing in a lying-in institution is, it need not be 
said, very large, and should be conducted quite at a distance. 
Sink-baths, for immediately putting in water soiled-linen, are 
necessary. 

12. Medical Officer's Room and Waiting-room. 

No dispensary, especially no dispenser, is needed in a 
lying-in institution, 

A medical officer's room is ^ecessary. The medical officer 
is not resident. He makes his morning and evening visit, and 
is called in by the head midwife for any difficult case. He 
gives instruction, scientific and practical, to the pupil mid- 
wives. [These lectures are given in the pupil midwives' 
mess-room.] 

In the medical officer's room should be kept the instru- 
ments, to which a fully qualified head midwife also has a 
key. The medical officer keeps the notes of cases, &c., and 
of instruction to the pupil mid wives in this room. 

The few, very few, drugs needed in a good lying-in insti- 
tution are kept here, or in the head midwife's sitting-room, 



86 NOTES ON LYING-IN INSTITUTIONS. 

A waiting-room is necessary. 

There must be a room where the head midwife can 
examine a woman, to know if labour is imminent. 

This might be done in the medical officer's room or the 
waiting-room. 

13. Segregation Ward. 

A ward is unfortunately necessary, completely isolated, 
where a sick case, brought in with small-pox or erysipelas 
or the like, could be dehvered and entirdy separated from 
the others, or where a case of puerperal fever or peritonitis 
(though such ought never to arise after deUvery in a properly 
constructed and managed institution) could be transferred. 
But if, unfortunately, puerperal fever should appear in the 
hospital, no new admissions should be allowed until the 
buildings have been thoroughly cleansed, hme-washed, and 
aired. 

The segregation ward must have a nurse's room, and a 
provision of sink, slop-sink, &c. 

14. Kitchen. 

The kitchen should be well placed, conveniently near, yet 
sufficiently cut off from the main corridor by a neck of pas- 
sage and intermediate offices. 

SITE. 

The site of a lying-in institution must be open, airy, sur- 
rounded with its own grounds, not adjoining or near to any 
other building, still less to any hospital or any nuisance 



SITE, 87 

or source of miasm. But it must be in the immediate 
vicinity of any large centre of population from which the 
lying-in women come. 

And this involves the question of receiving-rooms. 

Should there be a receiving-room, as well as a waiting- 
room? 

The lying-in woman's name is put down for admission 
some time beforehand. 

Lying-in hospitals differ as to their rules whether or no to 
admit women any time before labour is imminent. K they 
are not so admitted, they often have to be sent back again 
home. 

It is now beheved to be the soundest principle that the 
fewer days a lying-in woman spends in a lying-in institution, 
beyond the time she is actually under treatment, the better ; 
and this involves that she should not be admitted till labour 
is imminent — even at the risk of the infant being born in 
cab or lift (which has happened). 

Lying-in institutions must (unfortunately) be, therefore, 
in the immediate neighbourhood of great towns or centres 
of population. 

[Even those London Boards which are building their 
excellent new workhouse infirmaries in the country, are 
forced to keep their lying-in wards in the old workhouses in 
the town.] 

The difference, howevet, as has been shown by our 
statistics, is not so great between the mortality of women 
lying-in at home in the country and in the town as should 
make us pronounce against lying-in institutions in great 



88 NOTES ON LYING-IN INSTITUTIONS. 

centres of population — provided they have a large and 
entirely isolated area completely to themselves, perhaps a 
proportion of two acres to fifty beds. 

But this involves another question. 

A large proportion, alas I of workhouse lying-in women 
(we have seen two-thirds at Liverpool ^) are unmarried. Of 
these many have no home. 

It is difficult to send these women back again, even if 
labour is not actually imminent. And it is impossible to 
send them out after delivery, till recovery is fairly confirmed. 

In workhouses the question is solved by women being 
admitted into the body of the house during pregnancy, and 
discharged into the body of the house, if not to their own 
homes, when quite convalescent. 

In Liverpool Workhouse fourteen days after labour the 
lying-in women are thus discharged. Fourteen, eighteen, 
twenty-one days, are the average of a woman's stay in the 
lying-in division in London workhouses. 

A soldiers' wives' hospital takes in no unmarried women 
to he-in. 

Civil lying-in institutions almost invariably have to make 
exceptions and take in unmarried women. 

In workhouses they are not the exception, they are the 
rule. Married women are the exception. 

It is to be observed that married women will rarely come 
in an hour before, or stay an hour after it is necessary, in 
any lying-in institution. 

Ten to twelve days is ' the average period of hospital 

' In some London workhouses it is yet larger. 



AVERAGE STAY IN LYING-IN WARDS. 89 

treatment' in Colchester, Woolwich, and other soldiers' 
wives' lying-in hospitals. ' Women of this station of life 
cannot, as a rule, be prevailed upon to submit to longer 
detention,' it is added. 

The average number of days in King's College Hospital 
lying-in ward was sixteen. None were permitted to leave 
under fourteen days. Twenty-one days were allowed^ in 
ordinary cases. It is feared this might be too long ; but so 
very many weakly, half-starved women sought admission, 
that to send some away sooner was ' to ensure a break- 
down,' it is stated. 

In a civil lying-in institution it would not be by any 
means desirable absolutely to exclude single young women 
primiparce ; it would be grievous to some of these poor 
things to be sent among the (often hardened) wretched 
women of the workhouse. The whole question of these 
poor young women — unmarried mothers of a first child — is 
full of difficulty. It would never do, morally, to make 
special provision for them. And for this very reason we 
seem bound to receive such, conditionally, into well regu- 
lated lying-in institutions, and afford some kindly care to 
prevent, at the very least, their sinking lower. But it 
would not be right to leave any admissions for single 
women in the hands of any young assistant, or morally 
inexperienced person. 

The principle appears to be that, if pregnant women 
are to be received some time before and kept some time 
after delivery, the excess of time should not be passed in 
the lying-in wards, but in separate accommodation. 



90 NOTES ON LYINiG-IN INSTITUTIONS. 



n. MANAGEMENT. 

Construction, however, in a lying-in institution, holds 
only the second place to good management in determining 
whether the lying-in patients shall live or die. And without 
such management, no construction, however perfect, will 
avaiL 

And the first elementary principle of good management is 
to have always one pavilion of four or eight beds, according 
as it is of one floor or of two, standing empty in rotation 
for purposes of thorough cleansing. A fortiori — one 
delivery paviUon on each floor is always to be vacant 
alternately. 

The pavilion to be in rotation unoccupied for the purposes 
of cleansing must necessarily be the whole pavilion, with all 
its sculleries and ward ofiices, since the process of cleansing 
is — ^turning out all the Uttle fiimiture a lying-in ward ought 
ever to possess, bringing in lime-washers, possibly scrapers 
and painters, leaving doors and windows open all day, and 
even all night. 

Every reason for having each ordinary paviUon ward 
completely separate, and individually pavilionised^ apphes 
with tenfold force to the delivery ward. Each must be 
complete in itself, with aU its appurtenances and bye-ward 
for extreme cases, as a little pavilion. There is no possi- 
bility for properly cleansing and lime-washing the delivery 
ward not in use, unless this be the case. 

One delivery ward, however spacious and well arranged 



FIRST RULE OF MANAGEMENT. 91 

constantly used, would be a centre of deplorable mischief 
for the whole institution. This makes tuoo delivery wards 
for each floor of the institution indispensable, to be used 
alternately for the whole floor at given periods. 

N.B. Liverpool Workhouse with 25 lying-in beds, ex- 
clusive of delivery beds, has had an average of 500 de- 
liveries a year for eleven years. A civil lying-in hospital 
in or near a large town is generally jv^t as fuU as it is 
permitted to be. Five or six hundred deliveries or more a 
year might be reckoned upon ; occasionally three or four 
deUveries a night. Sculleries wiU be always in use, day and 
night. All this renders it imperative that an inexorable 
rule should be made and kept to, viz. that every lying-in 
pavilion should be vacant in rotation, each delivery pavilion 
alternately, for thorough cleansing. 

2. The second elementary principle of good management 
is to remove every case of illness arising in the institution, 
and every such case admitted into the institution, at once to 
an isolated sick ward or infirmary ward. 

This is mtist, not may. 

Though we should have no puerperal fever or peritonitis 
in a building of this make^ yet unfortunately other insti- 
tutions will send in (say) erysipelas or small-pox patients 
seized with labour. 

Sad experience tells that this unprincipled practice has 
often proved fatal to many other inmates of the lying-in 
institution, turning an institution into a hospital. 

Every sick case should therefore be completely isolated, in 
a separate sick ward, fi:om the lying-in women. And if 



92 NOTES ON LYING-IN INSTITUTIONS. 

admitted before delivery, her delivery should take place in 
this separate ward. 

N.B. The nurse's dinner and meals may be prepared in 
the general kitchen and sent to her. The patient's arrow- 
root, gruel, &c., must be made, and her beef-tea warmed, in 
the ' sick or segregation ' building, and all Unen must be 
sent to the ward well aired. 

Is it desirable to connect the * segregation ' ward by any 
covered passage with the rest of the lying-in institution ? 

There is much to be said for and against. 

The ward, it is to be hoped, will not often have to be 
used at alL 

But small-pox has appeared after labour. 
. There might be danger in taking a patient from the 
institution to this ward through the open air, in all weathers, 
unprotected by any covered passage. 

On the other hand, when once the patient is in the ward, 
complete isolation is by far the best, for the sake of all the 
others. 

And there is by no means the same necessity for a 
passage as in the other parts of the institution where any 
night there may be three or four ordinary delivery cases to 
be conveyed through the passages. 

A covered ambulance for sick cases is not, however, a nice 
thing, though often suggested.^ 

^ The only difficulty is as to protecting the patient (a lying-in woman) 
during the transit in cold or wet weather ; but perhaps some cover might be 
contrived for the bed or litter on which she is carried, which would be light, 
easily removable, and which could be exposed to the free action of the open air 
when not in use. . 



THIRD RULE OF MANAGEMENT. 93 

3. The first two may be called universal and essential 
principles of good management in every Ijdng-in institution, 
large or small, however perfectly constructed. 

Here is a third, hardly less essential, wherever there is 
more than one bed to a ward, viz. to remove a lying-in 
woman three times during her stay in the institution. 

The average course of an ordinary case may be reckoned 
thus : — 

Seven or eight hours in the delivery ward. 
Five or six days in the lying-in ward. 
Nine or ten days in the convalescent ward. 

The nearer wards to the delivery ward in use should 
always be made the wards for women immediately after 
delivery; the farther wards for the same women when 
removed for their convalescent stage. 

In a single-bed ward the woman may remain in her 
own ward from after her delivery till her discharge ; that 
is, no further removal after her delivery is necessary. 

4. Cases of extreme exhaustion after delivery, which are 
better out of the delivery ward yet cannot be moved many 
yards, should be carried in their beds to the bye-ward 
adjoining the delivery ward, till they are somewhat re- 
covered. 

These must have a constant watcher by them. 

5. In a lying-in institution about three times the quan- 
tity of Unen and bedding for each patient is necessary of 
what is used at a general hospital. 

The day's and night's provision of linen is kept in each 
ward scullery, and in the scullery of each dQlivery ward in 
use. 



94 NOTES ON LYING-IN INSTITUTIONS. 

The linen- store in the store-room, and the bedding-store, 
need to be very complete and ample. 

The bedding, that is, the mattress and blankets, of any one 
bed in the delivery ward should not be used for more than 
three or four delivery cases in succession without undergoing 
some process of purification — and this quite independent of 
any accident, the mattress of course being protected by 
Macintosh sheeting. 



Ill, TRAINING SCHOOL FOR MIDWIVE8. 

The few words which will here be added on the manage- 
ment of a midwifery training school are not at all to be 
understood as a manual for practical instruction, which it is 
quite impossible to introduce here, but as simply treating of 
the management, in so far as this determines some construc- 
tive arrangements as imperative, and others as to be avoided. 

No charity or institution, I beheve, could possibly bear 
the expense of a single-bed ward, or even of a four-bed ward 
lying-in establishment, for a pretty constant succession of 
thirty-two patients, unless there were a training school. 

[Thirty-two single-bed wards, an administrator would say, 
would require sixteen nurses, independently of midwives ! I] 

Even with a training school, the first year would be one 
of great difficulty, since all well managed training schools 
* take in ' pupils as much as possible at only two periods of 
the year, so as never to have the whole of the pupils fresh 
hands at once. But the first batch must necessarily be all 
fresh hands. A raw girl cannot be turned in to sit up with 



TRAINING SCHOOL FOR MIDWIVES. 95 

a newly-delivered woman and new-bom infant. And a 
midwife cannot be spared to each girl all to herself, to 
teach her how to handle an infant. [That is, in each single- 
bed ward.] 

The whole nursing service of a large four-bed or one-bed 
ward lying-in institution is so complicated, so different from 
that of a general hospital with its 20 or 32-bed wards, that 
it is difficult to provide for. 

In even guessing at what the nursing accommodation 
should be for so completely new an experiment as a lying- 
in institution of 40 beds in single-bed or four-bed paviUons, 
we must begin by stating the probable requirements, the 
whole being tentative. 

The staff would have to be at least as follows : — 

One matron. 

One head midwife. 

One assistant midwife. 

One deputy assistant midwife (for the first year). 
To establish a really good training school, 

Thirty pupil midwives. 

[Two experienced good nurses in addition might be ne^ 
cessary for the first year.] 

One cook. 

One housemaid. 

One or two other female servants, such as scourers — or 
more (number required depending on the flooring used). 

Though this staff appears enormous, it is calculated upon 
the plan of giving only one night nurse to every four beds, 
— upon the supposition that 32 occupied beds will give a 



96 NOTES ON LYING-IN INSTITUTIONS. 

constant succession of cases, enough to provide instruction 
for almost as many pupil mid wives ; — upon the principle that 
for systematic instruction there must be a fair number of 
pupils ; as, if every moment of their time is occupied in active 
duties, they cannot be well trained; — and also upon the 
obvious fact that it would be impossible, from its extrava- 
gance, to nurse such a construction without pupils. 

[For the second year, if a portion of the pupils are to be 
made thorough midwives, and their time of training two 
years, possibly the deputy-assistant midwife, and probably 
both the nurses, might be dispensed with. 

The second-year pupil midwives ought to be quite com- 
petent, each to be in charge of two or three first-year's 
pupils and several patients, taking these patients from the 
beginning, and teaching pupils to handle new-bom infants, 
look after ordinary lying-in cases, and the Uke ; and most 
excellent practice it is for the young teachers.] 

As to scourers, the nature of the floors decided upon will 
determine what are wanted. 

Also, none of the midwives can be expected to be house- 
maids, even in their own rooms. They have too much 
to do. The pupil midwives would be expected to clean 
their own bed-rooms, but not to scour, either for the patients 
or for themselves. 

There must be a common room for pupil midwives. 
Here they take their meals in detachments. Head midwife, 
as a rule, with first detachment ; matron carving. Here 
they receive lectures and instruction from the physician 
accoucheur. 

The matron must have two rooms. 



TRAINING SCHOOL MANAGEMENT. 97 

The head midwife may have two rooms. She will expect 
to have her tea in her own room* 

The head midwife, her assistants, and all her staff, should 
be lodged in a central position, and there should be ready 
means of communication witb these quarters, both by beUs 
and speaking tubes, from each pavilion and delivery ward. 

A regular night service in a lying-in institution being im- 
possible, the head midwife, when she goes her last roimd at 
night, say between eleven and twelve P.M., stations other 
watchers for any emergency arising besides those now to be 
mentioned, who are for the night nursing of ordinary cases. 

For this one pupil would probably be told off for each 
four wards or beds, and one extra for the whole floor, who 
must not be an inexperienced pupiL Her duty would be 
to visit each pavilion on her floor, and to have all in readiness 
in the delivery ward for cases coming in at night — a not 
infrequent occurrence. 

The head midwife would also arrange for the special care 
of any critical case at once, on the patient being conveyed 
to her own ward, or to that adjacent to the delivery ward. 

In so large and therefore busy a lying-in institution, it 
would not be desirable to call up all the pupil midwives to 
every case coming in the night. They would be appointed 
day by day alternately, and the number told off for the 
purpose would be called to any case coming that night. 

It is therefore most desirable that the sleeping-rooms ot* 
compartments (each with its own window) of the pupil 
midwives should be arranged in at least three reliefs, so that 
the occupants of one dormitory, or relief, could be called by 

H 



98 NOTES ON LYING-IN INSTITUTIONS. 

a bell from the delivery ward ringing into that dormitory 
without needlessly disturbing others. 

In so large an institution the head midwife even cannot 
attend every night case. 

The assistant must be a well qualified midwife, who can 
take her turn in attending night cases, calling the head 
midwife if necessary. 

Through all this organization, however, as far as possible, 
each pupil is told oflf to be in charge of a mother and in- 
fant from beginning to end. 

And there will always be unfortunately a certain number 
of cases, each requiring a nurse constantly by her side 
day and night. 

It is obvious that the same woman cannot do this for a 
succession of days and nights. 

But the number of severe cases requiring it would un- 
questionably be much smaller in a single-bed ward hospital, or 
in a four-bed ward hut hospital, because of its superior im- 
munity from puerperal disease ; though, from the single-bed 
ward condition, every such case will require a nurse all to 
itself. And the same nurse cannot be always sitting up day 
and night. 

N.B. Kepetitions may possibly here be pardoned. The 
pupil midwife appointed as night watcher for the whole 
floor cannot be depended upon to attend the bell of any in- 
dividual watcher. She may be absent at a delivery. 

Yet the life of an infant, e,g.^ in convulsions, depends on 
minutes — on the watcher being able to summon immediate 
help, hot water for a bath, and the like. 



PUPIL MIDWIVES. 99 

Those appointed to be called in such emergency should 
therefore be readily communicated with by bells or other- 
wise, without disturbing others, either nurses or patients. 

As there are no sleeping-rooms for any midwife or pupil 
in the ward pavilions, it is necessary to insist upon this — 
that there should be every facility for their being rung up 
or called up at night. 

Every pupil midwife ought to have a little bedroom to 
herself, or at least a compartment with half a window, or 
better a whole window, to itself. There should be a bath- 
room and W.C. on each floor in the pupil nurses' quarter?, 
and a back staircase. 

If a small sick-room could be managed for pupil mid- 
wives, it would be advisable. Where there are so many, 
one may be attacked with bronchitis or with scarlatina. 
She could not, of course, be * warded * with the lying-in 
women ; and it might be undesirable to leave her in her 
own little room, though this is quite sufficient for any shght 
illness. The top floor, as securing greater quiet, and a 
certain degree of isolation, might be the best for this sick- 
room. 

The whole of the pupil midwives' quarters should have 
direct and ready means of communication with the hospital 
proper. Each relief should be independent of the other 
two, and under the immediate supervision of the official 
woman, whose quarters are attached to its own. 

It need scarcely be stated that an essential part of a Pupil 
Midwife's training is to attend lying-in women at their own 
homes, with the conveniences or rather Hhe inconveniences 

h2 



100 NOTES ON LYING-IN INSTITUTIONS. 

of those homes. Otherwise the Pupil will be the less fit for 
her after-work. The last two months of every six might 
well be given to this. But, as above said, these ' Notes ' 
about management, for they are nothing more, simply treat 
of it as regards construction, and do not refer to the neces- 
sary training, either in-door or out-door, at all.^ 

DESCRIPTION OF SKETCH-PLANS OF PROPOSED 

INSTITUTION. 

I know of no single building which requires more in- 
genuity to plan, and has hitherto received less, than a lying- 
in institution, especially with a training school for midwives 
attached. 

Lieut. Ommanney, E.E., has been kind enough to give 
his time and mind to the subject — having previously had 
considerable experience at the War Office in planning female 
hospitals — and to embody the whole of the working accommo- 
dation required for both lying-in institution and school in the 
thoughtfully arranged sketch-plans, Nos. m., IV., and V. 

The estimated cost of these plans is large ; but if we must 
have lying-in institutions at all, it is only ' penny wise and 
pound foolish' to cripple either space or necessary appli- 
ances, or the means of regularly and periodically vacating 
every ward and every ward-office destined for the use of 
lying-in women. 

^ For a great part of the foregoing details of management I am indebted to 
the valuable experience of her, who, as then Superior of the nursing at Kin/s 
College Hospital, conducted our Training School for Midwifery Nurses there, so 
kindly, so wisely, and so well, that its necessary breaking up was the more to 
be deplored by all. 



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BUILDING PLANS: WARD UNITS. 101 



Plan III. 

This plan shows a lying-in ward unit for the institution, 
together with its scullery and separate offices, and the rela- 
tion which these bear to the corridor of communication 
joining all parts of the hospital on each floor together. 

The measurements and other details shown on this plan 
are the result of repeated and careful consideration of the 
requirements already described ; and it is believed that in 
practice they would be found sufficient for every purpose. 

The four beds shown on it are not the minimum^ but the 
waximum number which, judging from all past experience, 
could be safely placed together. 

Plan IV. 

Shows a floor of one of the lying-in ward paviHons, 
divided into four separate one-bed rooms. This plan 
also represents a unit, but of another construction. Thq 
great advantage of the arrangement is complete separation 
of cases from each other, so that each room is as far as pos- 
sible assimilated to a room in a private dwelhng-house. To 
obtain this advantage the rooms are arranged in pairs on 
each side of a nine-feet passage, having a window at one 
end and a corridor-window opposite the other end. 

Two of the rooms open jfrom the corridor, and two 
rooms from the passage, but the doors are not opposite each 
other. In this, as in the four-bed ward plan, the scullery and 
offices are completely isolated from the rooms by a nine-feet 



102 NOTES ON LYING-IN INSTITUTIONS. 

corridor. In this case, also, the measurements and other 
details have been arrived at after full consideration. This 
plan would be somewhat more costly than the previous one 
(Plan m.). The justification of it is found in the fact that 
it reproduces, in a permanent form, the conditions in 
Colchester Lying-in Hut, already described. And in this 
hut there has, as yet, been no death after delivery. 

Plan V. 

A lying-in institution for forty beds (thirty-two to thirty-sie 
occupied)^ with a training school for thirty pupil mid wives 
and midwifery nurses. 

This plan gives a sketch of an arrangement of paviUons, 
offices, quarters, &c., forming a complete lying-in institution 
and training school. As already stated, such an institutiom 
must, from its very objects, be situated in a town where land 
is scarce and valuable, and this is a chief difficulty in 
erecting it. Hence it has been necessary to keep the dif- 
ferent parts as close together as possible, and yet not to 
crowd them so as to interfere injuriously with the external 
ventilation. The mere architecture, as will be seen, has been 
subordinated to this necessity, but it must be borne in mind 
that utility, and not architectural effect, is to be sought 
for. 

In the centre of the plan project the quarters for pupils, 
on three floors, ten quarters on each floor. They are ar- 
ranged in this way to enable the reliefs to be taken from one 



BUILDING PLANS: PROPOSED INSTITUTION. 103 

floor at a time. Behind these, in the same block, are 
quarters for matron and midwives, waiting-room, surgery, 
stores, kitchen, and pupils' dining-room. The general en- 
trance is in one side of the centre block. The two front 
pavilions, on either side the centre, contain the delivery 
wards, two on each floor. Each delivery pavilion contains 
a ward for three beds on each floor, with its bye-ward and 
offices. Only one dehvery pavilion will be in use at one 
time. While one -pavilion is in use, the other will be vacant, 
and undergoing ventilation and cleansing. These delivery- 
wards are connected with the centre, and with all the 
pavilions on each floor by a nine-feet corridor, with cross- 
light and ventilation. Fire-places are shown for warming 
in winter. On the ground-floor are three four-bed wards, 
with offices, on each side, on the construction shown on 
Plan in. There will thus be twenty-four lying-in beds, and 
six delivery beds (but three delivery beds and 20 lying-in 
beds only in use at the same time) on the ground floor. The 
second pavilion from the front, on each side, is only one 
storey in height, so as to afford a freer circulation of air among 
the pavilions in the space within which it might be necessary 
to place them. 

As a consequence of this arrangement there would be 
only four lying-in wards, of four beds each, on the upper 
floor, together with a dehvery ward at each side (one de- 
livery ward to be used at a time). 

A special detached ward for febrile cases is shown 
behind the building. 



104 NOTES ON LYING-IN INSTITUTIONS. 

The total accommodation in an establishment of this size 
would be sufficient for 6 simultaneous deliveries and 32 to 
36 lying-in women* There would be 6 delivery beds 
always resting, and 4 or 8 lying-in beds always unoccupied. 
There would be training accommodation and facilities for 30 
pupils. 



i; 



I 

i 





FIRST FLOOR PLAN 



*'*A/ H1NHAHTLITH 



APPENDIX, 



MIDWIFERY AS A CARJEER POR EDUCATED WOMEN. 

My dear Sisters (or rather, Chers et tr^s-honor& Confreres), 

While all that we women think about is to have the same 
education as men in medicine, must we not feel the women's medi- 
cal movement to be rather barren when it might be so fruitful ? 

But public opinion in England is not free enough for a coward 
to dare to say what she thinks, unless at the risk of having her 
head (figuratively) broken. 

Is there not a much better thing for women than to be * medical 
men,' and that is to be medical women ? 

Has not the cart been put before the horse in this women's 
medical movement ? 

Here is a branch so entirely their own, that we may safely say 
that no lying-in would be attended but by a woman if a woman 
were as skilful as a man — a physician accoucheur. 

Yet, instead of the ladies turning all their attention to this, 
and organising a midwifery school of the highest efficiency in both 
science and practice, they enter men's classes, and lectures, and 
examinations, which don't wish to have them, and say they want 
the same education as men. 

Then, is there not an immense confusion as to whether they are 
ever to be called in as medical attendants to men ? 

* No,' say those lady doctors who have at all thought out the 
question. ' We wish to be educated as if we were going to attend 



106 APPENDIX, 

meiij but we should think it an insult to be called in to attend 
men.' 

Why not adjourn for a century, or for half a century, the ques- 
tion whether all branches of medical and surgical practice shall 
be exorcised by women, even upon women ? It is a question 
which may safely be left to settle itself. 

But here is a matter so pressing, so universal, so universally 
recognised, viz., the preferable attendance of women upon women 
in midwifery, that it may really be summed up thus : — Although 
every woman would prefer a woman to attend upon her in her 
lying-in, and in diseases peculiar to her and her children, yet the 
woman does not exist, or hardly exists, to do it. Midwives are 
so ignorant that it is almost a term of contempt. 

The rich woman cannot find fully qualified women, but only 
men to attend her, and the poor woman only takes unqualified 
women because she cannot afford to pay well-qualified men. 

But why should the midwives be ignorant ? and why (in the 
great movement that there is now to make women into medical 
men) should not this branch, midwifery, which they will find no 
one to contest against them — not at least in the estimation of the 
patients — be the first ambition of cultivated women ? Is there 
any rational doubt that, suppose there were a man and a woman, 
both equally versed in midwifery art and science, the woman 
would be the one sent for by all lying-in women ? 

There is a better thing than making women into medical men, 
and that is making them into medical women. 

Surely it is the first object to enable women, by the most thorough 
training, practical and scientific, to practise that branch of the art 
of medicine which all are agreed should be theirs, not * like men ' 
— for nearly all the best men are agreed how deficient are the 
practical training and opportunities of medical students, es- 
pecially in midwifery, which deficiency yet does not prevent them 
from obtaining diploma, license, all they want, in order to prac- 
tise — not Mike men' then, but like women, like women who wish 
to be real physician accoucheuses ; that is, to attend and to be 



MIDWIFERY AS A CAREER FOR EDUCATED WOMEN. 107 

consulted in all deliveries, abnormal as well as normal, in diseases 
of women and children, as the best accoucheurs attend and are 
consulted. 

Sensible women say, ^ But the only means to obtain a scientifio 
education is to enter men's classes/ 

Id that the case ? 

Is the student's scientific and practical education all that could 
be wished ? 

Could there not be given (and ia there not given, in some 
Continental schools ?) a far more thorough and complete scientific 
education, as well as practical, where there are none but women, in 
a midwifery school, without all this struggle and contest, which 
raises questions so disagreeable and ridiculous that a woman of 
delicate feeling shuns the indelicacy of the contest — not the in- 
delicacy of the occupation ? 

The parody, the qui pro quo, is a curious one. 

The indelicacy of a man attending a ^woman in her lying-in is 
by necessity overlooked. 

The indelicacy of a woman attending with men in medical 
classes is made much of. 

Would it not be far better to get rid of both at once ? to have 
women — trained with women, by women — to attend women^ 
trained in all branches of a scientific and practical midwifery 
education ? 

But let no one think that real midwifery education can be less 
complete and thorough for a woman than it ought to be for a 
man, if women are really to be physician accoucheuses. 

And let no one think that two or three courses of lectures — a 
month, three months, six months at a lying-in institution, con- 
ducting twenty, thirty, or one hundred labours — will make a 
woman into a (real) midwife. 

One hundred labours may be normal, requiring no interference 
but that which a good midwifery nurse can give. The one hun- 
dred and first may be abnormal and may cost the patient her 
life or health, the attendant her reputation and peace, if her 



108 APPENDIX. 

education has been nothing but the few lectures, the few weeks, 
the few labours. 

Let us suppose for a moment that, leaving aside the ordinary 
talk of giving a woman a * man's medical education,' good or bad, 
we imagine what a college might be to give the whole necessary 
training — medical, scientific andpractical — ^to make real midwives, 
real physician accoucheuses. 

There must be first, of course, the lying-in institution, the de- 
liveries conducted by fully qualified head midwives, of whom 
enough perhaps exist already for this purpose, who will give prac- 
tical instruction to the pupil midwives at the bedside. 

There must be a staff of professors, to give scientific instruction 
in midwifery, but also in anatomy, physiology, and the like ; in 
pathology and pathological branches; above all, in sanitary 
science and practice. 

Dissections and post-mortem examinations will have to be 
practised. It need not be said that these must be at a quite 
different time and place in the * course of education ' from the 
training about the lying-in patients. 

Probably all these professors, or nearly all, must at first be 
men. 

Probably in time all these professors, or nearly all, will come to 
be women. 

The course of education, before the end of which no pupil can 
receive the certificate of a fully qualified midwife, must oertainly 
not be less than two years. 

/8 this merely an ideal?. la it an Utopia? Have we never 
seen it in practice ? Could it not be put in practice in practical 
England ? 

Seen it in practice we have — save and except thd sanitary 
practice, which is wofuUy deficient— on the continent of Europe. 

And lady professors there have been in midwifery on the Con- 
tinent quite equal to the most distinguished physician accoucheurs 
in this or in any other country ; who took their place among these. 



MIDWIFERY AS A CAREER FOR EDUCATED WOMEN. 109 

among the Sir James Simpsons and the Sir Charles Lococks, as 
o/them, and not outside of them, in all midwifery matters, scientific 
as well as practical. 

The names of Madame Boivin and Madame Lachapelle, of Paris, 
are known to all Europe. And there are many other names of lady 
professors in midwifery and of midwives, not known in England at 
all, who take their imcontested places on the continent in practice, 
in consultation, in teaching, as a Sir James Simpson here. They 
teach in midwives' colleges, and imperial and royal ladies are 
sometimes, and often wish to be always, attended by them. 

Note. — A society has already existed for several years, the 
object of which, according to its programme, is Ho provide 
educated women with proper facilities for learning the theory 
and practice of midwifery, and the accessory branches of medical 
science.' 

The programme states most justly that, for want of these, for 
want of * proper means of study,' of * any public examination,' 

* any person may undertake the duties of a midwife.' 

Let us look what the ' proper means of study ' are which it 
provides. 

They are — 1. Attendance upon lectures during two winter 
sessions. 2. Attendance ' during the intervening summer ' upon 
clinical practice at * a ' lying-in hospital or maternity charity, 
with personal attendance upon at least twenty-five deliveries ! 

[It is easy to make a rough calculation how many cases of 
abnormal parturition occur to how many normal. Is it likely 
that among 'twenty-five deliverieg^' there will be abnormal cases 
enough to practise the pupil-judgment, the pupil-hand ?] 

These ladies have not even the advantages which the idlest 
student can hardly help availing himself of — and hia minimum is 

* three years.' Yet this is the course proposed to enable a woman 
to ' practise midwifery,' even in the sense in which we understand 
a man to ' practise midwifery,' — to enable a woman to become a 



110 APPENDIX, 

physician accoucheuse (for these ladies are expressly styled ' ac- 
coucheuses ') in the sense in which we understand a man to be a 
physician accoucheur. 

The paper states, doubtless with truth, that these ladies ^ are 
the best taught accoucheuses hitherto accessible to the English 
public' May we not hope that, in future years, the society will 
be enabled to give * accoucheuses ' still better taught 'to the 
English public'? 



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Little on Spinal Weakness 
Liveing on Skin Diseases . 
Lonsdale's Life of Heysham . 
Loudon's Encyclopsedia of Plants 
Lubbock on the Origin of Civilisa 

tion .... 
Marcet oft Diseases of the Larynx 
Marshall's Outlines of Physiology 
Maunsell's Dublin Midwifery . 



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Mill on the Human Mind . 
Mill's Hamilton's Philosophy . 

System of Logic 

Miller's Elements of Chemistiy 

Inorganic Chemistry . 

Mitchell's Assaying . 
Moore on Rodent Cancer 
Morehead on Disease in India 
Morell's Mental Philosophy 
Murchison on Diseases of the Liver 
Nightingale's Notes on Hospitals 
Nilsson's Stone Age in Scandi 

navia 

Odling's Animal Chemistry . 

Outlines of Chemistry . 

Practical Chemistry 

Manual of Chemistry . 

Lectures on Carbon . 

Owen's Comparative Anatomy and 

Physiology of Vertebrata 
Paget's Surgical Pathology 
Pereira's Manual of Materia Medica 
Ponton's Banning 
Proctor on Plurality of Worlds . 

on the Sun . , 

Reimann on Aniline . 

Riche's Medical Chemistry . 

St. Bartholomew's Hospital Report: 

Skey on Hpteria . 

Smith's Philosophy of Health . 

Stebbing's Analysis of Mill's Ix)gic 

Thomson's Conspectus, by Birkett 

Todd and Bowman's Anatomy and 

Physiology of Man . 
Tyndall on Diamagnetism and Mag 

ne-Crystallic Action 
Tyndall's Faraday as a Discoverer 

Fragments of Science 

Lectures on Sound 

Heat . 

Notes on Light and Elec 

tricity .... 
Ure's Dictionary of Arts, Manufac 

tures, and Mines 
Watson's Principles and Practice of 

Physic .... 
Watts's Dictionary of Chemistiy. 
Webb's Celestial Objects for Com 

mon Telescopes 
West on the Diseases of Children 

How to Nurse Sick Children 

Williams on Climate of South of 

France .... 
Winslow on Light 
Wood's Chemical Notes 
Notes on the Metals . 



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